Remote Area Urgent Care Facilities

HEALTHCARE DEVELOPMENT ORGANIZATION
Medical Designated Facilities Department

Medical Consulting and Quality Assurance Division
Remote Area Clinic Group
Remote Area Urgent Care Facilities

Minimum Medical Standards Requirements Manual
2009
Copyright 2009, Saudi Aramco. All rights reserved. No part of this manual may be reproduced in any form or
by any means without the express written consent of Saudi Aramco.
Disclaimer of Liability: The information enclosed in this manual is intended as a reference guide only, and if
implemented it should enhance the Remote Area Medical Facilities standard of care. Medical standards of care
and practice are dynamic and it is therefore critical that facilities providing medical services keep up-to-date
with current clinical and Industry Standards and Practices. Information provided in this manual is accurate at
the time of publishing, but Saudi Aramco emphasizes that it does not assume any legal liability or responsibility
for the accuracy, completeness, or usefulness of any information disclosed in herewith and that no guarantees,
expressed or implied are made.
Healthcare Development Organization

Medical Consulting & Quality Assurance Division
Remote Area Urgent Care Facilities Group

Bldg. 554, Room G10, Box 76
Dhahran Health Center
June 14, 2009

MINIMUM MEDICAL STANDARDS REQUIREMENTS MANUAL (MMSR)
To ensure safe practice and deliverance of quality health care to all patients receiving medical care at the
work site, Medical Designated Facilities subject matter experts, have put together this Manual to be used as
a reference to assist organizations setup, evaluate and monitor the standards of patient care mandatory at
Remote Area Clinic health care system.
The requirements within this manual are based on the Ministry of Health (MOH) regulations, Saudi Labor Law
and Saudi Aramco Standards (Saudi Aramco Safety Manual, section 28-Medical) and are therefore mandatory for all SA Proponent Organization and/or Contractor Companies performing work at Saudi Aramco job
sites in Saudi Aramco remote areas and/or industrial settings.
Should you require help with the technical aspects of using this manual, one of our advisors will be happy to
meet with you. For further information please contact the Remote Area Urgent Care Facilities Group Leader.
He can be contacted at 03-877-3459 or 03-877-3338.
This manual was collated by Janet R. Acevedo, Health Educator.
Improving the quality of health care to all patients is a very broad, comprehensive and ambitious undertaking, which can only be achieved by working together.
Thank you for your cooperation.
Jacques D. Cheong, Quality Assurance Coordinator

Dr. Mohd Fawzy Younis, Chief

Medical Consulting and QA Division
Dr. Saad A. Missmar, Director

Dr. T.Q. Al-Daiel, General Manager

Healthcare Development Organization
Table of Contents
Section 1 Introduction
How to Use the MMSR Manual . ....................................................................................... 1
Definition ......................................................................................................................... 1
Section 2 Initial Category/Level Evaluation
Instructions of Usage ........................................................................................................ 2
Evaluation Form ................................................................................................................ 2
Final Category/Level Selection ........................................................................................... 3
Section 3 Survey and Compliance Review Report for Category ABC Facilities
Health Care Provisions at Remote locations ....................................................................... 4
Building Specifications ...................................................................................................... 7
Manpower Requirements/Hours of Operation ................................................................... 14
Staff Qualification, Experience, Competency, Continuing Education and
Education/Training Records................................................................................................ 15
Safety Requirements ......................................................................................................... 21
Environmental Health and Infection Control Requirements ................................................ 27
Medical Equipment and Medical Supplies Requirements . .................................................. 31
Pharmaceutical Services..................................................................................................... 44
Support Services:
Ambulance Services .......................................................................................................... 53
Communications .............................................................................................................. 57
Janitorial Services .............................................................................................................. 58
Medical Emergency and Disaster Response/Medivac Procedures ........................................ 62
Quality Improvement Requirements .................................................................................. 69
Patient Processing and Medical Records ............................................................................ 70
Health Care Policies, Procedures and Guidelines ................................................................ 71
General Regulations . ........................................................................................................ 74
Section 4 Survey and Compliance Review Report for Category D Facilities
First Aid Provisions in Remote Areas General Regulations ............................................... 76
First Aid Provisions in Remote Areas First Aid Requirements ............................................ 77
Section 5 Attachments .............................................................................................. 83
Section 6 References..................................................................................................148
Section 7 Appreciation ..............................................................................................149
This manual is for nonprofit, noncommercial use only, and may not be sold. It is being published by Saudi
Aramco as part of a services enhancement program to improve Remote Area Medical Facilities standards of care.
Section 1 Introduction
How to Use the MMSR Manual
The MMSR Manual is to be used by any Proponent Organization (Saudi Aramco and/or Contractor) to:
1. Select the Most Appropriate Level of Medical Facility - The Initial Category Evaluation Sheet
specifies the criteria for each category/level and therefore allows the proponent organization to evaluate
and determine the most appropriate level of first aid services and category of medical facility it must
provide at the work site in remote areas and/or industrial settings.
2. Setup a Medical Facility - The Survey and Compliance Review Report specifies the required
mandatory minimum medical standards for first aid services and medical facilities at the work site in
remote areas and/or industrial settings.
3. Monitor Compliance at Medical Facility - The Survey and Compliance Review Report can be used
as a tool to monitor and evaluate the mandatory minimum medical standard requirements for first aid
services and medical facilities, including privately owned facilities, operating at Saudi Aramco work sites.
Definition
1. Minimum Medical Standard Requirements Are the minimum acceptable standards for first aid
services and medical facilities at the work site in remote areas and/or industrial settings as specified in the
Saudi Labor and Workmen Law, Saudi Aramco Safety Manual, General Instructions and policies and in
the Ministry of Health (MOH) mandatory regulations.
2. Remote Area Urgent Care Facilities - Are medical facilities operating at industrial work sites in a
remote area, able to provide first aid, urgent care, pre-hospital care, stabilization and prompt transfer of
sick and injured employees to the nearest definitive care facility. Also, they are able to provide medical
assistance in the event of a disaster.
3. Remote Areas - Are areas of operation, which by distance or topography, are isolated from any medical
facility capable of providing an opportunity and prompt response to an emergency situation. These
include:
Areas accessed by tracks or dirt roads, such as pipeline corridors and skid roads.
Areas which are far from inhabited areas, developed roads or landing strips.
Areas over open water.
Areas accessed by off-road travel, even if it is near paved roads, towns or industrial facilities.
Examples include offshore locations and off-road locations (i.e., drilling rigs, deep desert exploration, and
refining and distribution areas).
We hope the information provided facilitates your efforts in ensuring that medical facilities at the work site in
remote areas and/or industrial settings meet the mandatory standards of practices so you are able to provide
a safe patient care environment and quality care to all patients and employees.
We wish you the best of luck in this very important endeavor.
Section 2 Initial Category/Level Evaluation

Instruction of Usage
1. First: Fill in the required information on the Evaluation Form.
2. Second: Use the criteria listed on the checklist below to evaluate and select the category/level of medical
facility your organization requires to provide safe and quality health care to all employees at the work
site. The determining factors must be looked at collectively before a final category is selected. Complete
the Final Category/Level Selection () section at the end of page 3.
3. Third: Go to the appropriate section of the survey and compliance review report as indicated in the
Final Category /Level Selection () to identify the minimum standard requirements for your selected
category.
Evaluation Form
Name of Project: __________________________
Name of Medical Facility: ____________________
Name of Company: __________________________________________________

Contact Details:
Tel. No.:________
Category of
Medical
Facilities
2.
3.
4.
1.
CATEGORY/LEVEL B
Physician operated facility,
small size without
laboratory and radiology
services
2.
3.
4.
CATEGORY/LEVEL C
Nurse operated
facility
Mobile No.:________
e-mail Address:
Criteria: The following factors are used to determine the category (level)
of medical facility required to meet the health needs of your employees
at the work site.
1.
CATEGORY/LEVEL A
Physician operated facility,
large size with laboratory
and radiology services
Fax No.:_______
1.
2.
Tick
Here
Employee population exceeds 50 workers in a single location

or within a radius of 15 kilometers.
Access to medical care: The company operates at a remote
area/location where inpatient medical facilities are not available in the
area to refer patients for definitive care or/and timely transfer of
patients for definitive care is not possible.
Risk factors: The work site is potentially high risk for accidents,
disasters or explosions. Possibility of mass casualties is high.
Specialized services: In view of the remoteness of company
operation, providing on-site specialized medical procedures,
diagnostic or otherwise, will be cost-effective and benefit company
operation.
Employee population exceeds 50 workers in a single location
Access to medical care: The Company operates at a remote
area/location where only a limited number of inpatient medical
facilities are available in the area to refer patients for definitive care
and/or timely transfer of patients for definitive care may be
difficult.
disasters or explosions with possibility of mass casualties.
Specialized services: Providing on-site specialized medical
procedures, diagnostic or otherwise, will be cost-effective and benefit
company operation.
Employee population amounts 50 workers in a single location
Access to medical care: The Company operates at a remote
area/location where inpatient medical facilities are available in the
area to refer patients for definitive care and timely transfer of
patients for definitive care is possible. The company has an
established medical support and logistic network, e.g., a referral
system for the duty nurse to immediately consult a physician for
advice and treatment and the capability to arrange an immediate
transfer or medivac.
2
Category of
Medical
Facilities
Criteria: The following factors are used to determine the category (level)
of medical facility required to meet the health needs of your employees
at the work site.
3.
CATEGORY/LEVEL C
Nurse operated
facility (Cont.)
4.
1.
CATEGORY/LEVEL D
First Aid Kits/
Cabinets
Tick
Here
disasters or explosions with low possibility of mass casualties.
Specialized services: Specialized procedures can be provided at a
company designated hospital. It will not be cost-effective or benefit
company operation to have this service provided on-site.
Employer who employs less than fifty (50) workmen shall provide at
the work site a first aid cabinet. And shall assign an appropriate
number of his workmen to receive first aid training. (Saudi Arab
Government Decision No. 404, Articles I-VI dated 17 Jamada 11,
1494 (July 7, 1974 and Saudi Aramco GI-150.002.)
Specialized Services include Radiology, Laboratory, physicals, and other tests/procedures preformed as part
of the companys health conservation program, e.g., hearing test and pulmonary function test.
Final Category/Level Selection ():
Complete Section 13 of the Survey and Compliance Review Report
G
D
Remarks:
Name of Assessor: __________________________________________________________

Signature: _____________________________________________ Date: ______________________
3
Section 3 Survey and Compliance Review Report for Category ABC Facilities
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level A, B and C Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write NA Where not Applicable
Item
Code
1.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
HEALTH CARE PROVISIONS AT REMOTE LOCATIONS
GENERAL REGULATIONS References: Saudi Labor Law, Section 28 of Saudi Aramco Safety Manual and Ministry of Health (MOH) Regulations.
1.1
Every contracting company which operates within Saudi Aramco remote

areas work sites shall provide medical care to all employees in accordance
with Section 28 of the Saudi Aramco Safety Manual, which incorporates
the relevant elements of Chapter 7 of Saudi Labor Law. At a minimum:
For more information, see Attachment 1-2, pages 84-86.
1.1-1
An employer who employs less than fifty (50) workmen shall

provide at the work site a first aid cabinet.
For more information, see section 4, pages 76.
1.1-2
An employer who employs fifty (50) or more laborers at a

minimum shall provide its employees with the following:
1.1-2-1
A first aid room at the work site. Depending on

needs, the first aid room can range from a single
room portable facility to a multi-room facility.
1.1-2-2
A Saudi MOH licensed nurse shall be on duty 24

hours a day, seven days a week (24/7).
1.2
Every proponent organization shall have a copy of the MMSR manual at

the work site medical facility for implementation, compliance and
reference purposes.
1.3
Every proponent organization shall provide healthcare as per the

mandatory insurance laws in the Kingdom of Saudi Arabia implemented in
1999 and 2003:
1.3-1
SCORE:
There is evidence that all employees, including subcontractor

employees, are registered in a 24 hour a day, seven days a week
(24/7), inpatient hospital.
YES = Meet Standards
NO = Does not Meet Standards
NA = Not Applicable

Item
Code
Standards
Review I
Date:
Yes
No
Review II
Date:
Yes
No
Comments
HEALTH CARE PROVISIONS AT REMOTE LOCATIONS (Cont.)
1.0
GENERAL REGULATIONS
1.4
SCORE:
1.3-2
There is evidence that all employees and subcontractor

employees are provided with health insurance coverage for
emergency and inpatient care including appropriate
investigations.
1.3-3
There is evidence that the organization designated an inpatient

hospital where a physician (specialist or otherwise) can be
consulted by the work site medical facility staff for further
advice, referral and/or transfer of patients as needed.
1.3-4
There is evidence that the organization maintains adequate

funds at all times in the proposed inpatient hospital. Current
documentation of advanced payment of agreed funds is
available upon request.
Every proponent organization shall have a database system that at a

minimum includes, but is not limited to the following information:
1.4-1
Employees name.
1.4-2
Employees ID number.
1.4-3
Employees medical registration (MR) number.
1.4-4
Name of Medical Facility.
1.4-5
Medical insurance card number and level of medical coverage.
1.4-6
Proponent organization head office contact number.
1.4-7
Proponent organization 24 hour on-site representative contact

number.
1.4-8
Contact number of Saudi Aramco Supervisor overseeing the

contractor work.
1.4-9
All information above is kept current at all times.

NA = Not Applicable
5
5

Item
Code
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
HEALTH CARE PROVISIONS AT REMOTE LOCATIONS (Cont.)
1.0
GENERAL REGULATIONS
1.5
Every proponent organization at a minimum shall define their

organizational values as follows:
1.5-1
A vision, a statement about what the organization wants to

become.
1.5-1-1
1.5-2
A mission, an organization's vision translated into written

form. It materializes the management's view of the direction and
purpose of the organization.
1.5-2-1
1.6
1.6-1
Basic Life Support (BLS).
1.6-2
First Aid (FA).

1.6-2-1
SCORE:
Mission statement is posted.
Every proponent organization shall ensure that there is at least one (1)
crew member per shift with basic level of medical care awarded by a
recognized training program (Saudi Red Crescent Society or Saudi Aramco
Health Promotion Unit as applicable). At a minimum training includes,
but is not limited to:
For more information see Saudi Aramco GI-150.002
1.6-1-1
1.7
Vision statement is posted.
Current certificate available upon request.

Every proponent organization shall ensure that their medical facilities

healthcare professionals have the required Government license to practice
their profession in the Kingdom. At a minimum all professional staff is
registered and licensed by the following government bodies:
For more information, see Attachment 3, page 91.
1.7-1
Saudi Council for Health Specialties (SCFHS).
1.7-2
Ministry of Health (MOH).

NA = Not Applicable
66

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
BUILDING SPECIFICATION
2.A General Standards

2.A.1
Every proponent organization shall ensure that their medical facilities have
signage available as follows:
2.A.1-1
Writing/information is clear and concise.
2.A.1-2
At a minimum it contains the following information/details in

both English and Arabic:
2.A.1-3
2.A.2
SCORE:
2.A.1-2-1
Hours of operation.
2.A.1-2-2
Staff availability including regular and emergency

contact numbers.
Signage is posted at the entrance point to the facility.
Every contractor company shall ensure that their medical facilities

buildings are provided with following necessities. At a minimum these
include, but are not limited to:
2.A.2-1
Each room has air conditioning.
2.A.2-2
Floors are covered with sheets of seamless, non-slip vinyl

flooring.
2.A.2-3
Walls are painted with washable paint.
2.A.2-4
All areas within the facility have sufficient electrical power.
2.A.2-5
All electrical power outlets are ground protected.
2.A.2-6
All doors are fire-rated.
2.A.2-7
Floor mounted base cupboard units with seamless laminated

work top, as needed.
2.A.2-8
Wall mounted cupboards in quality laminate finish, as needed.
NA = Not Applicable
7
7

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
BUILDING SPECIFICATION (Cont.)
2.A General Standards (Cont.)

2.A.2-9
2.A.2-10
2.A.2-11
2.A.2-12
Sinks (wash basins) are available in the following areas:

2.A.2-9-1
Patient care areas.
2.A.2-9-2
Bathrooms.
2.A.2-9-3
Physicians examination room.
Sinks (wash basins) are available with the following:
2.A.2-10-1 Hot and cold water.
2.A.2-10-2 Liquid soap dispenser.
2.A.2-10-3 Disposable paper towel dispenser.
Trash bins are available in all patient care areas.
Facilities that have an ambulance bay, shall provide the
following:
2.A.2-12-1 A double entrance door as follows:
With sufficient width to enable
easy-access of ambulance
stretcher.
An ambulance bay as follows:
2.A.2-12-2-1 Sheltered.
2.A.2-12-1-1
2.A.2-12-2
2.A.2-12-3
With wall mounted power

outlet to connect the
2.A.2-12-2-2
ambulance auxiliary air
conditioner unit.
2.A.2-12-2-3 With water tap and hosepipe.
An ambulance ramp is available.
2.A.2-12-3-1
SCORE:
Ramp is correctly positioned

and leveled.
NA = Not Applicable
8
8

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
2.A General Standards (Cont.)

2.A.2-13
2.A.3
SCORE:
Telephone lines are available in the following areas:

2.A.2-13-1 Business office.
2.A.2-13-2 Nurse station.
2.A.2-13-3 Treatment area.
2.A.2-14 Facility has emergency exit(s) available as follows:
2.A.2-14-1 Exits are not obstructed, kept clear at all times.
2.A.2-14-2 Exit signs are available as follows:
2.A.2-14-2-1 Well illuminated.
Exit signs are not obstructed,
2.A.2-14-2-2
kept clear at all times.
Internally facility is well illuminated with acceptable (30 foot2.A.2-15 candles or 300 Lux) intensity light. Areas include but are not
limited to:
2.A.2-15-1 Inpatient examination area.
2.A.2-15-2 Treatment areas.
There are emergency lights strategically placed
2.A.2-15-3
for power failure.
2.A.2-16 Externally facility is well illuminated.
2.A.2-17 All facility fabrics internally and externally, are well maintained.
2.A.2-18 Evacuation map is available.
2.A.2-18-1 Map is displayed at all times.
Every contractor company shall ensure that all new buildings (fabric and
contents) are inspected and certified as compliant to the required Saudi
Aramco (SA) building specifications and Safety and Loss Prevention
standards and Environmental Health standards prior to occupation.
NA = Not Applicable
9

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
2.B Specific Standards

Category/Level A Facilities
2.B.1
All facilities in this category shall be a fixed land-based or a portable

building with multiple rooms. Floor plan must satisfy traffic flow and
functional needs (e.g., easy patient observation, Radiology and Laboratory
facilities access and utilization).
2.B.2
Every contractor company in this category shall ensure that their medical
facilities have the following areas of operation:
SCORE:
2.B.2-1
Business office with reception.
2.B.2-2
Patient waiting area.
2.B.2-3
Emergency treatment /observation room.
2.B.2-4
Separate bathrooms as follows:

2.B.2-4-1
Patients/visitors.
2.B.2-4-2
Staff, only.
2.B.2-5
Staff room.
2.B.2-6
Nurse station, screening and examination.
2.B.2-7
Store room with level shelving.
2.B.2-8
Janitor room with the following:

2.B.2-8-1
Floor sink.
2.B.2-8-2
Water tap.
2.B.2-8-3
Storage facility (shelving/steel cabinet).
2.B.2-9
Pharmacy area.
2.B.2-10
Laboratory area.
2.B.2-11
Radiology area.
2.B.2-12
Physicians room.
NA = Not Applicable
1010

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

Laboratory Services
2.B.3
Must be in compliance with all the building specifications and standards in

relation to Safety, Environmental Health and Infection Control as specified
by MOH regulations.
Radiology Services
2.B.4
Must be in compliance with all the building specifications and standards in

relation to Safety, Environmental Health and Infection Control as specified
by MOH regulations.

Category/Level B Facilities
2.B.5
SCORE:
11
2.B.5-1
Business office with reception.
2.B.5-2
2.B.5-3
2.B.5-4
Pharmacy room (dispensing and storage).
2.B.5-5

2.B.5-5-1
Patients/visitors.
2.B.5-5-2
Staff, only.
2.B.5-6
Staff room.
2.B.5-7
Nurse station, screening and examination.
2.B.5-8
2.B.5-9
Physicians room.
NA = Not Applicable
11

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

Category/Level B Facilities
2.B.5-10

2.B.5-10-1
Floor sink.
2.B.5-10-2
Water tap.
2.B.5-10-3
Category/Level C Facilities
2.B.6
All facilities in this category have a fixed land-based or portable building

with one or more rooms depending on the facilitys scope of service and
functional requirements. Open floor plan is preferred for multi-rooms
building.
For floor plan sample, see Attachment 26-27, pages 146-147.
2.B.7
As indicated below, exempt are certain areas at single room portable
building in onshore rigs or at single assigned room in offshore operations.
SCORE:
2.B.7-1

Not applicable to single room portables.
2.B.7-2
Nurse screening and examination area.
2.B.7-3
2.B.7-4

2.B.7-4-1
Patients/visitors.
2.B.7-4-2
Staff, only.
NA = Not Applicable
12
12

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

Category/Level C Facilities
2.B.7-5

2.B.7-6
Staff room.
2.B.7-7

2.B.7-7-1
Floor sink.
2.B.7-7-2
Water tap.
2.B.7-7-3
Staff on-site/Camp Accommodation

2.B.8
Every contractor company shall ensure that their employees are provided
with appropriate accommodation, either as an integral part of the facility
or in the camp.
2.B.9
If accommodation is provided in the camp, contractor company shall

ensure that the location is very near to the medical facility building to
enable prompt emergency or disaster response.
2.B.10
Every contractor company shall ensure that their staff accommodation

facilities are provided with following necessities/standards. At a minimum
these include, but are not limited to:
SCORE:
13
2.B.10-1
Room size shall be no less than 4.6 sq. meter (50 sq. feet) per
individual occupancy, excluding bathroom and shower.
2.B.10-2
Air conditioning.
NA = Not Applicable
13

Item
Code
2.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

Staff on-site/Camp Accommodation
2.B.10-3
3.0
Bathroom with the following:

2.B.10-3-1
Toilet.
2.B.10-3-2
Sinks (washbasin).
2.B.10-4
Shower with hot and cold running water.
2.B.10-5
Smoke detector.
2.B.10-6
Refrigerator.
2.B.10-7
Linen supplies.
2.B.10-8
Access to laundry facilities.
MANPOWER REQUIREMENTS/HOURS OF OPERATION
General Standards
3.1
Every proponent organization has a backup plan in place to provide

coverage for unplanned emergencies, holidays, sickness, off-duty days,
absences and other unplanned events.
3.2
Every contractor company shall ensure that for all matters pertaining to
clinic operation, all registered nurses (RN) are under the direct supervision
of a senior RN or physician. Distant supervision is acceptable and contact
for advice/consultation shall be available 24 hours a day, seven days a
week (24/7).
3.3
A work schedule detailing staffs duty hours to cover a 24/7 operation is

available and posted.
3.4
SCORE:
An on-call schedule for off-duty hours must be available and posted with
respective contact numbers.
NA = Not Applicable
14
14

Item
Code
4.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS
A. General standards
4.A.1
Each proponent organization shall ensure that there is an appropriate

recruitment system to select medical staff.
4.A.2
There is evidence that the recruitment system has a process for reviewing
and approving resumes/CVs and carrying out pre-hire interviews as
required.
4.A.3
There is evidence that resumes/CVs of healthcare candidates are reviewed

by relevant experienced healthcare professionals (physician, registered
nurse, pharmacist) noting experience, qualifications and clinical
competency.
B. Staff Education and Competency

4.B.1
There is an employee New Hire Orientation (NHO) program in place.
4.B.2
There is a mechanism in place to provide all staff with continuing

education.
4.B.3
There is a mechanism in place to provide all staff with periodic mandatory

education. At a minimum this includes, but is not limited to:
4.B.3-1
Basic Life Support (BLS), every two (2) years.
4.B.3-2
Fire safety, yearly.
4.B.3-3
Infection control, yearly.
4.B.4
All mandatory education shall remain current and completion of all

courses shall be documented and made available upon request.
4.B.5
Where special clinical tests and procedures are approved as part of the
scope of service, a list of these tests and procedures is available.
4.B.6
Where special clinical tests and procedures are carried out, staff shall
receive appropriate training and certified competent to perform these
and/or competent to use associated equipment including performing
manufacturers required calibration.
SCORE:
15
NA = Not Applicable
15

Item
Code
4.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS (Cont.)
B. Staff Education and Competency
4.B.7
Each proponent organization shall ensure that their staff has access to
reference/education materials to keep them current with clinical standards
and practices and with their professional/education requirements. A
minimum of one (1) book (latest edition) for each of the following
category shall be made available:
4.B.7-1
Nursing Practice.
4.B.7-2
Emergency Care.
4.B.7-3
Anatomy and Physiology.
4.B.7-4
EKG Interpretation.
4.B.7-5
Pharmacology.
4.B.7-6
Clinical Practice.
4.B.7-7
4.B.7-8
First Aid (FA).
4.B.7-9
Trauma Care.
4.B.7-10
Merck Manual.
4.B.7-11
Physicians Desk Reference.

Physician operated facilities only.
C. Staff Records
4.C.1
All documents (certified) relating to employees past experience,

professional qualifications and references must be available for verification
upon request.
4.C.2
Each employee has personnel file containing all documents related to his
employment (i.e., personal details, professional licensing, certificates,
education and training history, performance appraisals, disciplinary actions
and communications).
SCORE:
NA = Not Applicable
1616

Item
Code
4.0
Standards
Review I
Date:
Yes
No
Review II
Date:
Yes
No
Comments
D. Staff Specific Qualifications

Nurses Requirements:
4.D.1
To practice his profession in the Kingdom, a nurse is registered and

licensed by the following government bodies:
4.D.1-1
Registered with Saudi Council for Health Specialties (SCFHS),

prior to work site assignment.
4.D.1-2
When registration is under process, nurse shall have a valid

SCFHS registration card or a follow-up card with K number
only until registration card is issued.
4.D.1-3
Has a valid Saudi MOH license within 6 months of hire.
4.D.2
Must be graduated from an approved nursing school, 3-4 years basic

course and registered in their country of origin.
4.D.3
Able to operate emergency medical equipment. At a minimum

equipment includes, but is not limited to:
4.D.4
4.D.5
4.D.3-1
Automatic Electronic Defibrillator (AED).
4.D.3-2
Intravenous (IV) pump.
4.D.3-3
Airway management adjuncts.
Nurse has basic level of medical care from a recognized training

program/institution (Saudi Red Crescent Society (SRCS) or Saudi Aramco
(SA) Health Promotion Unit (HPU)) prior to work assignment. At a
minimum this includes, but is not limited to:
4.D.4-1
Basic Life Support (BLS), current certificate.
4.D.4-2
First Aid (FA), current certificate.
Must have minimum 2 years Emergency Room experience.

4.D.5-1
SCORE:
17
Evidence of recent practice, less than 2 years.
NA = Not Applicable
17

Item
Code
4.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Nurses Requirements:
4.D.6
4.D.7
Each proponent organization shall ensure that their staff completed an

emergency skills competency assessment prior to being assigned to work
independently. Competency assessment determines the employees
readiness to practice independently. Program details and performance
appraisal (assessment) is available upon request. At a minimum
assessment includes, but is not limited to following skills:
4.D.6-1
Airway Management.
4.D.6-2
Ability to administer BLS.
4.D.6-3
Ability to use at least six (6) types of emergency equipment.
4.D.6-4
Ability to manage at least 10 kinds of first aid.
4.D.6-5
Ability to manage at least six (6) kinds of emergencies.
4.D.6-6
Ability to activate a disaster response.
4.D.6-7
Ability to complete a pharmaceutical, drug familiarization

program.
Good written and verbal English language skills.
Physicians Requirements:
4.D.8
General practitioner with five (5) years experience in a hospital setting and
a minimum of one (1) year emergency room experience.
4.D.9
To practice his profession in the Kingdom, physician is registered and

licensed by the following government bodies:
4.D.8-1
4.D.9-1
SCORE:
Evidence of recent practice, less than 2 years.
Registered with Saudi Council for Health Specialties

(SCFHS), prior to work site assignment.
NA = Not Applicable
18
18

Item
Code
4.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Physicians Requirements:
4.D.10
4.D.11
4.D.9-2
When registration is under process, the nurse shall have a

valid SCFHS registration card or a follow-up card with K
number only until registration card is issued.
4.D.9-3
Has a valid Saudi MOH license within 6 months of hire.
Physicians have the basic level of medical care from a recognized training
program/institution (SRCS or SA - HPU) prior to work assignment. At a
minimum this includes, but is not limited to:
4.D.10-1
Basic Life Support (BLS), current certificate.
4.D.10-2
First Aid (FA), current certificate.
Ambulance Drivers Requirements:

4.D.12
Ambulance driver at a minimum meets the following work requirements:

4.D.12-1
Saudi driving license with minimum of one (1) year driving

experience.
4.D.12-2
A good driving record.
4.D.13
Secondary school certificate (L7-9), diploma or equivalent.
4.D.14
Ambulance driver has the basic level of medical care from a recognized
training program/institution (SRCS or SA - HPU) prior to work assignment.
At a minimum this includes, but is not limited to:
4.D.15
SCORE:
4.D.14-1
Basic Life Support (BLS), current certificate. Course in Arabic

is acceptable.
4.D.14-2
First Aid (FA), current certificate. Course in Arabic is

acceptable.
Good command of English language skills preferred.

NA = Not Applicable
19
19

Item
Code
4.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Ambulance Drivers Requirements:

4.D.16
Within two (2) weeks of site assignment completed a specific orientation

and on-the-job training (OJT) program, on the following: (Evidence of
completion available upon request.)
4.D.16-1
Familiarization with ambulance equipment/devices and how

to perform some basic functions.
4.D.16-2
Site location orientation.
4.D.16-3
Role and responsibilities in the event of an emergency

and/or disaster response.
4.D.16-4
Ambulance routine checks and maintenance.
Pharmacists Requirements:
4.D.17
A degree in pharmacy (Bachelor of Science [B.S.] and/or Master of Science

[M.S.] degree), recognized by the Saudi Arabian Government as eligible
for licensing.
4.D.18
Valid pharmacist license to practice in Saudi Arabia.
4.D.19
Minimum of three (3) years experience in hospital or clinical pharmacy.
4.D.20
Laboratory Technicians Requirements:

4.D.21
Bachelor of Science degree in medical technology or equivalent.
4.D.22
Valid license to practice in Saudi Arabia.
4.D.23
Three (3) years practical experience in a medical laboratory.
4.D.24
SCORE:
NA = Not Applicable
20
20

Item
Code
4.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Radiology Technicians Requirements:

4.D.25
Diploma in radiology technology.
4.D.26
Valid license to practice in Saudi Arabia.
4.D.27
Three (3) years general practical experience.
4.D.28
5.0
SAFETY REQUIREMENTS
5.1
fire safety equipment available. At a minimum this includes, but is not
limited to:
5.1-1
5.2
SCORE:
Fire Extinguishers as follows:

5.1-1-1
Appropriate fire extinguishers (A, B, C).
5.1-1-2
Clearly identified.
5.1-1-3
Placed in strategic locations.
5.1-1-4
Labeled with proof of periodic inspection, usually

quarterly.
5.1-2
Smoke detectors.
5.1-3
Scott Air Pak (At location where exposure to H2S is a risk).
eyewash station available as follows:
5.2-1
Unit is outside the facility building and in proper working order.
5.2-2
There is evidence that unit is regularly tested/inspected to ensure

it is in proper working order.
NA = Not Applicable
21
21

Item
Code
Review I
Date:
Yes
No
Standards
5.0
SAFETY REQUIREMENTS (Cont.)
5.3
decontamination shower available as follows:
5.4
5.3-1
Unit is in proper working order.
5.3-2
There is evidence that unit is regularly tested/inspected to

ensure it is in proper working order.
Comments

properly manage their compressed gas cylinders. At a minimum, the
following precautions and safety regulations shall be observed when
storing, handling, and using compressed gas cylinders in order to keep the
hazards to a minimum:
5.4-1
Pressure is checked and logged daily, log sheet available upon

request.
5.4-2
Cylinders are replaced when content reaches 500 pressure per

square inch (psi).
5.4-3
Cylinders are securely stored as follows:

5.4-3-1
Either on oxygen delivery carts, walls, or in a secure

storage cage.
5.4-3-2
In an upright position (valve end up), on a level floor.
5.4-3-3
Well ventilated and dry storage area.
5.4-3-4
In a storage room free from flammable substances

(i.e., oil and/or volatile liquids).
5.4-3-5
5.4-3-6
SCORE:
Review II
Date:
Yes
No
Away from direct sunlight and from other sources of

heat as cylinder temperatures must not exceed 50 C
(122 F).
All sources of ignition (i.e., motors, generators,
communication systems, etc.) are removed from the
storage room.
NA = Not Applicable
22
22

Item
Code
5.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

Empty cylinders are stored separate from full
cylinders.
5.4-3-8
Empty cylinders are marked empty.
No smoking signs are available and posted in areas where gas
5.4-4
cylinders are located and/or stored.
Microwave oven, if available, shall be managed by the medical facility as
follows:
5.5-1
Have operating instructions posted nearby.
5.5-2
Maintained clean and in good working order.
ELECTRICAL EQUIPMENT SAFETY - Every proponent organization shall
ensure that their medical facilities properly manage their electrical
equipment. At a minimum, the following precautions and safety
regulations are observed when using electrical equipment in order to
prevent injuries and keep hazards to a minimum:
All electrical equipment is in proper working order and safe for
5.6-1
use, does not tingle, shock, spark or get overheated.
5.6-2
Case or body of the item is not cracked, chipped or broken.
5.6-3
There are no exposed internal parts.
5.6-4
The controls (buttons) are complete and functional.
5.6-5
There is an off switch, when used, equipment turns off.
Units cord is intact (not damaged), has no cracks
5.6-6
and/or breaks.
5.6-7
Cord is not taped or covered.
Units plug is not damaged, has no cracks and/or
5.6-8
breaks.
5.6-9
Plug is directly secured to wall socket.
5.6-10
There is an extension unit secured to the wall.
There is evidence that equipment is periodically checked for
5.6-11
obvious defects or hazards.
5.4-3-7
5.5
5.6
SCORE:
23
NA = Not Applicable
23

Item
Code
5.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

There is evidence that defective equipment is removed from
service, has tags so that no other staff will attempt to use it.
5.6-13
All electrical equipment is ground protected.
MEDICAL EQUIPMENT SAFETY - Every proponent organization shall
ensure that their medical facilities have a system in place for the
management of their medical equipment. At a minimum, the following
precautions and safety regulations shall be implemented to ensure that
the medical devices meet appropriate standards of safety, quality and
performance:
There is a process in place for the maintenance/service of
medical equipment performed either by the company that
5.7-1
supplied the equipment or through an agent able to arrange
timely and reliable service.
There is an established process for medical equipment to go
through an initial acceptance test performed by a Clinical
5.7-2
Engineer prior to being put into service. A record of this test is
All patient care equipment must undergo periodic preventive
maintenance (PM) checks. This includes testing and calibration as
5.7-3
per manufacturer and local policy. PM stickers or log are placed
to indicate PM completion and next due date.
There is evidence that there is a backup system in place for
5.7-4
repairing medical equipment.
All equipment shall be checked daily for normal function and
5.7-5
findings are recorded in a log. Log is available upon request.
a system in place for reporting on-the-job/off-the-job of injuries. Injuries
shall be documented and reported to the MOH and Saudi Aramco Loss
Prevention.
5.6-12
5.7
5.8
SCORE:
NA = Not Applicable
2424

Item
Code
Review I
Date:
Yes
No
Standards
5.0
5.9
HAZARDOUS SUBSTANCES SAFETY - Every proponent organization

shall ensure that their medical facilities have a system in place for the safe
management/storage of hazardous substances as follows:
5.10
SCORE:
5.9-1
There is a Material Safety Data Sheet (MSDS) Manual available.
5.9-2
There is a current MSDS for each hazardous substances/

products used.
5.9-3
Manual is placed on a strategic location, easy to see and

reach.
5.9-4
Staff is able to quickly locate manual, shows/verbalizes

location.
5.9-5
Facility has appropriate antidotes for handling chemical

exposure.
Review II
Date:
Yes
No
Comments
FIRE SAFETY - Every proponent organization shall ensure that their

medical facilities have approved fire safety protocols in place. At a
minimum, the following safety requirements shall be implemented to
ensure the safety of patients/family, staff and visitors.
5.10-1
There is evidence that all staff is oriented on fire safety

(R.A.C.E. and P.A.S.S.).
5.10-2
Staff verbalizes what to do in the event of a fire: Rescue

injured person(s) from immediate danger, Activate nearest
fire alarm pull station, Confine the fire by closing all
doors/windows, Extinguish if fire is small/Evacuate if
instructed (R.A.C.E.).
5.10-3
Staff shows/verbalizes location of the nearest fire alarm.
5.10-4
Staff is able to operate fire alarm, in theory.
5.10-5
Staff shows/verbalizes location of the nearest fire extinguisher.

NA = Not Applicable
25
25

Item
Code
5.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

Staff demonstrates/verbalizes knowledge of the types of fire
extinguishers (A, B, C).
Staff is able to verbalize how to properly operate fire
extinguisher: Pull the pin at the top of the fire extinguisher.
5.10-7
Aim the nozzle at the base of the fire. Squeeze the handle of
the fire extinguisher together. Sweep the nozzle from side to
side (P.A.S.S.).
In the event of a fire staff knows/verbalizes the proper fire
5.10-8
evacuation procedures. Able to put into action, in theory.
Fire evacuation procedures are posted in appropriate/ strategic
5.10-9
locations, at all times.
Staff shows/verbalizes location of the nearest fire exit and
5.10-10
evacuation protocol.
EMERGENCY RESPONSE - Every proponent organization shall ensure
that their medical facilities have approved emergency response protocol in
place. At a minimum, the following emergency response requirements
shall be implemented to ensure timely emergency response in the event of
a disaster.
There is a disaster response plan in place and it is
5.11-1
implemented.
There is evidence that all staff is oriented on disaster response
5.11-2
procedures.
Disaster response plan is posted in a strategic location, at all
5.11-3
times.
5.11-4
Staff shows/verbalizes location of disaster response plan.
5.11-5
There is a current disaster call-out list of key personnel.
Disaster call-out list is posted in a strategic location, at all
5.11-6
times.
5.11-7
Staff shows/verbalizes location of the disaster call-out list.
5.10-6
5.11
SCORE:
NA = Not Applicable
2626

Item
Code
Review I
Date:
Yes
No
Standards
6.0
ENVIRONMENTAL HEALTH AND INFECTION CONTROL REQUIREMENTS
6.1
VACCINATION PROGRAM - Every proponent organization shall ensure

that their medical facilities have a vaccination program in place as follows:
6.2
SCORE:
6.1-1
There is a vaccination program for all open wound injuries and

is implemented.
6.1-2
Administered vaccines are appropriately logged in a book or

database.
6.1-3
As per MOH regulations, all staff before site assignment, shall

be screened and immunized as follows:
6.1-3-1
Chest X-ray.
6.1-3-2
Tuberculosis skin test (tuberculin or PPD test).
6.1-3-3
Hepatitis B (HBV) and Hepatitis C (HCV).
6.1-3-4
Human Immunodeficiency Virus (HIV).
6.1-3-5
There is evidence that screening and immunization

were completed.
Review II
Date:
Yes
No
Comments
Every proponent organization shall ensure that staff knows and complies
with the following standard precautions:
6.2-1
Hand washing.
6.2-2
Gloves.
6.2-3
Mask.
6.2-4
Handling sharps.
6.2-5
Cleaning of spills.
6.2-6
Patient placement (isolation).

NA = Not Applicable
27
27

Item
Code
Standards
Review I
Date:
Yes
No
6.0
ENVIRONMENTAL HEALTH AND INFECTION CONTROL REQUIREMENTS (Cont.)
6.3
Every proponent organization shall ensure that personal protective

equipment (PPE) is always available. At a minimum this includes, but is
not limited to:
6.3-1
Disposable masks.
6.3-2
Gloves.
6.3-3
Goggles.
6.3-4
Gowns.
6.3-5
Plastic aprons.
6.3-6
Safety shoes.
6.4
Facility ensures that sterilization is not performed by soaking in liquids,

boiling and/or steaming. This is NOT an acceptable practice.
6.5
Every proponent organization shall ensure that all CSS supplies

(instruments and packs) in their medical facilities are disposable. At a
minimum these include, but are not limited to:
6.6
SCORE:
6.5-1
Dressing packs.
6.5-2
Forceps.
6.5-3
Tongue depressors.
6.5-4
Dressing scissors (individual pack).
6.5-5
Suture pack.
Review II
Date:
Yes
No
Comments
All clinical areas have sinks (wash basins) available with the following:
6.6-1
Hot and cold water.
6.6-2
Antiseptic liquid soap.
6.6-3
Wall mounted paper towel dispensers.
6.6-4
Trash bins.
NA = Not Applicable
28
28

Item
Code
7.0
6.7
6.8
6.9
6.10
6.11
6.12
6.13
Review I
Date:
Yes
No
Standards
approved alcohol-based hand-rub, if sink(s) are not available.
Staff knows and is able to demonstrate appropriate hand sanitizing/ hand
washing technique as per established hand washing policy.
Examination tables are protected with disposable cover sheets or paper
rolls.
appropriate bactericidal available and that it is used to disinfect hard
surfaces.
Clean linen is stored in a protected clean area.
Soiled linen is placed (deposited) into covered, leak proof bags, as per
established criteria.
There are adequate puncture resistant, leak-proof sharp containers in all
clinical areas, as follows:
6.13-1
All clinical areas have sharp containers.
6.13-2
Sharp containers are wall-mounted.
6.13-3
Replaced when they are three quarters () full.
6.14
6.15
Healthcare providers are able to verbalize what to do in the event of a

needle stick/sharps injury.
6.16
Housekeepers are able to verbalize what to do in the event of a needle

stick/sharps injury.
SCORE:
29
Comments
There is no recapping of needles. If used needles are recapped, the scoop

method is used.
6.17
Review II
Date:
Yes
No
a system in place for the safe management (identification, segregation,
collection, storage, transportation, treatment and disposal) of infectious
wastes/biomedical waste, as follows:
System is in compliance with Infection Control (IC) guidelines
6.17-1
and is in accordance with MOH regulations.
NA = Not Applicable
29

Item
Code
6.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

Staff is familiar with and is able to verbalize the disposal
protocol (i.e., all sharps boxes are securely taped shut, double
boxed and transported to an approved agent for disposal).
two (2) dedicated refrigerators available, as follows:
6.17-2
6.18
6.18-1
Medication refrigerator is used for medications only.
6.18-2
Refrigerator is used for staffs food only.

Temperature is maintained between 2-8 degrees Celsius (3646 degrees Fahrenheit).
6.18-3
6.18-4
There is a thermometer available in each refrigerator.
Refrigerators temperature is recorded twice a day in a log

sheet. Log is available upon request.
Refrigerators are cleaned inside and out on a regular basis,
6.18-6
and when applicable, defrosted as needed.
adequate color-coded foot-operated waste bins, as follows:
6.18-5
6.19
6.20
6.21
6.19-1
For regular waste.
6.19-2
For infectious waste.
6.19-3
Bins are labeled.
blood spill kits available.
There is evidence that personnel responsible for cleaning and disinfecting
blood and body fluids spills are adequate trained.
Laboratory Services
6.22
SCORE:
Laboratory specimens are handled, stored and transported in accordance

with established policy/protocol.
NA = Not Applicable
30
30

Item
Code
Review I
Date:
Yes
No
Standards
7.0
MEDICAL EQUIPMENT AND MEDICAL SUPPLIES REQUIREMENTS
7.1

depending on their category and operational needs have adequate
quantity of medical and hospital equipment. At a minimum equipment
includes, but is not limited to:
7.1-1
Bag valve mask (BVM) with built-in CO2 detection device, (e.g.,
AMBU), adult, disposable.
7.1-2
Backboard, long with straps.
7.1-3
Dressing cart stainless steel (trolley).

7.1-4
Drug cupboard, lockable.
7.1-5
Wheel chair.
Not for single portable facility.
7.1-6
Automated external defibrillator (AED), portable with the

following monitoring capabilities:
7.1-6-1
Continuous cardiac monitoring.
7.1-6-2
Able to print strip.
7.1-6-3
Blood pressure measurement.
Review II
Date:
Yes
No
Comments
Oxygen saturation measurement.

Separate pulse oximeter is acceptable if the above
is not available on the AED.
Emergency response bag.
For more information see Attachment 15, page 120.
7.1-6-4
7.1-7
7.1-8
SCORE:
31
Exam/emergency stretcher with lockable wheels.

Stretcher without wheels acceptable at single room portable
facilities.
NA = Not Applicable
31

Item
Code
7.0
SCORE:
Standards
Review I
Date:
Yes
No
Review II
Date:
Yes
No
Comments
MEDICAL EQUIPMENT AND MEDICAL SUPPLIES REQUIREMENTS (Cont.)

7.1-9
Observation bed.
7.1-10
Entonox/nitronox unit, portable.
7.1-11
Examination light, wall mounted.
7.1-12
Refrigerators dedicated as follows:

7.1-12-1
For staff, small, medium or large.
7.1-12-2
For chilled items/drugs, small, medium or large.
7.1-13
Hare traction unit.
7.1-14
Infusion pump.
7.1-15
Intravenous (IV) pole/stand, mobile.

Due to space limitation in single room portables, any device
which facilitates the hook up of IV bag/bottle is acceptable.
7.1-16
Ophthalmoscope/otoscope, wall mounted and/or desk top.
7.1-17
Oxygen cylinder D size, wall secured or cart.
7.1-18
Oxygen cylinder E size, wall secured or cart.
7.1-19
Oxygen Resuscitation unit (e.g., Robert Shaw or Oxy-Viva

Resuscitator).
7.1-20
Portable emergency eye irrigation unit.
7.1-21
Stretcher emergency, disposable (e.g., Life lite emergency),

five (5) per box.
7.1-22
Stretcher, basket.
In single room facility, to be part of operation emergency
response supplies.
7.1-23
Weight/height scale.
7.1-24
Ring cutter.
NA = Not Applicable
3232

Item
Code
7.0
7.2
33
Review II
Date:
Yes
No
Comments

7.1-25
Scissors bandage.
7.1-26
Sharps disposable box for disposal of contaminated sharp.
7.1-27
Sphygmomanometer, aneroid type, desk top or wall mounted.
7.1-28
Stethoscope.
7.1-29
Suction: portable suction, Laerdal, with rechargeable batteries.
7.1-30
Thermometer: electronic thermometer.
7.1-31
Visual acuity chart.
7.1-32
Scoop stretcher with straps.
7.1-33
Glucometer machine, calibration safe.
7.1-34
Pocket mask with oxygen nipple/inlet.

quantity of standard medical supplies. At a minimum supplies include,
but are not limited to:
7.2-1
Abdominal pads.
7.2-2
Adhesive tapes, sizes include, but are not limited to:
7.2-3
SCORE:
Review I
Date:
Yes
No
Standards
7.2-2-1
inch.
7.2-2-2
1 inch.
7.2-2-3
2 inch.
AED - electrodes and other accessories.

NA = Not Applicable
33

Item
Code
7.0
Standards
Review II
Date:
Yes
No
Comments

7.2-4
Airways oral, guedal, disposable, sizes include, but are not

limited to:
7.2-4-1
Small.
7.2-4-2
Medium.
7.2-4-3
Large.
7.2-5
Alcohol preps.
7.2-6
Aluminum foil, roll.
7.2-7
Anal scope, disposable.

Not for Cat. C facilities.
7.2-8
Applicators sterile, 6 inch.
7.2-9
Applicators non-sterile, 3 inch.
7.2-10
Apron, plastic.
7.2-11
Bag: paper bag, preferable waxed.
7.2-12
Band aids.
7.2-13
Bandages stockinet, sizes include, but are not limited to:
7.2-14
SCORE:
Review I
Date:
Yes
No
7.2-13-1
2 inch.
7.2-13-2
4 inch.
Bandages ace, sizes include, but are not limited to:

7.2-14-1
2 inch.
7.2-14-2
3 inch.
7.2-14-3
4 inch.
7.2-14-4
6 inch.
NA = Not Applicable
34
34

Item
Code
7.0
Standards
35
Review II
Date:
Yes
No
Comments

7.2-15
Bandages, triangular.
7.2-16
Basins, kidney shape, disposable.
7.2-17
Batteries at a minimum include, but are not limited to:

7.2-17-1
1.5 volts, D cell.
7.2-17-2
1.5 volts, AA.
7.2-17-3
1.5 volts, AAA.
7.2-17-4
Spare for AED.
7.2-17-5
Chargeable for EKG machine, spare.
7.2-18
Bandage scissors.
7.2-19
Betadine swabs and/or solution sticks.
7.2-20
Blood spill kit.

For details and contents, see Attachment 7, page 95.
7.2-21
Body bags.
7.2-22
Burn dressing, sterile burn sheet 60 x 90 cm.
7.2-23
Burn pad 55 x 75 cm.
7.2-24
Butterfly cannulas, sizes include, but are not limited to:
7.2-25
SCORE:
Review I
Date:
Yes
No
7.2-24-1
19 gauge.
7.2-24-2
21 gauge.
7.2-24-3
23 gauge.
Catheters nasal, sizes include, but are not limited to:

7.2-25-1
18 french.
7.2-25-2
16 french.
NA = Not Applicable
35

Item
Code
7.0
Standards
Review II
Date:
Yes
No
Comments

7.2-26
Suction catheters, sizes include, but are not limited to:

7.2-26-1
14 french.
7.2-26-2
16 french.
7.2-27
Catheterizations set urethral, size 14 french, disposable.
7.2-28
Cervical collars, hard, stiff neck brand only, sizes include, but
are not limited to:
7.2-28-1
No neck adult.
7.2-28-2
Small adult.
7.2-28-3
Regular adult.
7.2-29
Cold packs.
7.2-30
Cotton balls, sterile, 10 packs.
7.2-31
Cardio Pulmonary Resuscitation (CPR) board.
7.2-32
Glue, derma bond.

Not for Category C facilities.
7.2-33
7.2-34
7.2-35
SCORE:
Review I
Date:
Yes
No
Drain Penrose, sizes include, but are not limited to:

7.2-33-1
inch.
7.2-33-2
1 inch.
Dressings include but are not limited to:

7.2-34-1
Non-adhering.
7.2-34-2
Disposable dressing pack.
7.2-34-3
Tegaderm, 6 centimeter x 7 centimeter (cm).
7.2-34-4
Multi-trauma dressing, sterile.
Ear speculum dispenser.

NA = Not Applicable
3636

Item
Code
7.0
7.2-36
Ear speculum.
7.2-37
Ear wash syringe.
7.2-38
Electrocardiogram recording paper.
7.2-39
EKG adaptor clips/pads or suction bulbs.
7.2-40
EKG electrodes, disposable if applicable.
7.2-42
Comments
Elastoplasts, sizes include, but are not limited to:

7.2-41-1
inch.
7.2-41-2
1 inch.
7.2-41-3
3 inch.
Emergency blankets at a minimum include, but are not

limited to:
7.2-42-1
Aluminum polymer, body heat retainer.
7.2-42-2
Disposable emergency blankets, size 58 inch x 90

inch.
7.2-43
Emergency eye wash solution, 16 ounce bottle.
7.2-44
Eye pads, sterile.
7.2-45
Filter, pocket mask.
7.2-46
Splinter forceps, fine tip disposable.
7.2-47
37
Review II
Date:
Yes
No
7.2-41
SCORE:
Review I
Date:
Yes
No
Standards
Roller gauze, non-sterile, sizes include, but are not limited to:
7.2-47-1
1 inch.
7.2-47-2
2 inch.
7.2-47-3
3 inch.
7.2-47-4
4 inch.
NA = Not Applicable
37

Item
Code
7.0
Standards
Review II
Date:
Yes
No
Comments

7.2-48
7.2-49
7.2-50
7.2-51
7.2-52
7.2-53
7.2-54
7.2-55
7.2-56
7.2-57
SCORE:
Review I
Date:
Yes
No
Gauze sponges, non-sterile, sizes include, but are not limited

to:
7.2-48-1 2 x 2.
7.2-48-2 3 x 3.
7.2-48-3 4 x 4.
Gauze sponges, sterile, sizes include, but are not limited to:
7.2-49-1 2 x 2.
7.2-49-2 3 x 3.
7.2-49-3 4 x 4.
Gloves examination, non-sterile, latex.
Gloves examination, sterile, latex. sizes include, but are not
limited to:
7.2-51-1 7.
7.2-51-2 7 .
7.2-51-3 8.
Glucometer control solutions, as applicable.
Safety goggles.
Head immobilizer.
Humidifier disposable with adapter, Aquapak, 500 milliliters
(ml).
Portable emergency eye wash set.
Intravenous (IV) catheters Jelco, sizes include, but are not
limited to:
7.2-57-1 14 gauge.
7.2-57-2 16 gauge.
7.2-57-3 18 gauge.
7.2-57-4 20 gauge.
7.2-57-5 22 gauge.
NA = Not Applicable
3838

Item
Code
7.0
Standards
7.2-59
7.2-60
7.2-61
7.2-62
7.2-63
7.2-64
7.2-65
7.2-66
7.2-67
7.2-68
7.2-69
7.2-70
7.2-71
7.2-72
39
Review II
Date:
Yes
No
Comments

7.2-58
SCORE:
Review I
Date:
Yes
No
IV set, primary and piggyback pump set for pump type.

IV tubing (nitroglycerin set) for IV pump.
IV tubing, 15 drops set.
IV tubing, metriset.
Kerlix rolls.
Kleenex tissue.
Lancets.
Laryngeal Mask Airways (LMA), disposable, sizes include, but
are not limited to:
7.2-66-1
3.
7.2-66-2
4.
7.2-66-3
5.
Laryngeal mask airway holder.
Face mask, disposable.
Medicine cups.
Micropore tape, sizes include, but are not limited to:
7.2-70-1 inch.
7.2-70-2 1 inch.
7.2-70-3 2 inch.
Nebulizer sets.
Needles, sizes include, but are not limited to:
7.2-72-1 18 gauge, 1-1 inch.
7.2-72-2 20 gauge, 1 inch.
7.2-72-3 22 gauge, 1- inch.
NA = Not Applicable
39

Item
Code
7.0
Standards
Review II
Date:
Yes
No
Comments

7.2-73
Optivisor.
7.2-74
Oxygen connecting tubes.
7.2-75
Oxygen flow meter, to fit various size cylinders.
7.2-76
Oxygen masks adult, simple.
7.2-77
Oxygen masks, non-breathing, adult.
7.2-78
Oxygen nasal cannulas, adult.
7.2-79
Paper roll for examination table (e.g., Vanco).
7.2-80
Paper cups.
7.2-81
Paramedic scissor/sheer.
7.2-82
Penlight torch/flashlight.
7.2-83
Percussion hammer.
7.2-84
Pleur evac drainage.

7.2-85
Red dot monitoring electrodes.
7.2-86
Safety pins, large.
7.2-87
Safety hard hat, size to fit.
7.2-88
SCORE:
Review I
Date:
Yes
No
Scalpel handle, disposable with the following:

7.2-88-1
Blades number 11.
7.2-88-2
Blades number 20.
7.2-89
Shroud Kit.
7.2-90
Sharps boxes (SB) at a minimum include, but are not limited

to:
7.2-90-1
SB with wall brackets, large.
7.2-90-2
SB with wall brackets, small.
7.2-90-3
SB small, ambulance.
NA = Not Applicable
4040

Item
Code
7.0
7.2.92
Comments
Spandages at a minimum include, but are not limited to:

7.2-91-1
S-01, small, child's finger, toes, with applicator.
7.2-91-2
S-02, adult finger, toes, with applicator.
7.2-91-3
S-03, hand, lower arm, wrist, ankle.
7.2-91-4
S-04, large hand, foot, upper arm, elbow.
7.2-91-5
S-05, large arm, small leg, knee, amputations.
7.2-91-6
S-06, large leg, knee, amputations, IV / armboard.
7.2-91-7
S-07, wound trauma bandaging system.
Splints cardboard, sizes as follow:

7.2.92-1
Arm, 12 inch.
7.2.92-2
Leg, 12 inch.
7.2.92-3
Arm, 18 inch.
7.2.92-4
Leg, 18 inch.
7.2.92-5
Leg, 24 inch.
7.2-93
Saline, irrigation, 1,000 cc, sterile.
7.2-94
Steri-strip at a minimum include, but are not limited to:
7.2-95
41
Review II
Date:
Yes
No

7.2-91
SCORE:
Review I
Date:
Yes
No
Standards
7.2-94-1
inch.
7.2-94-2
1/8 inch.
Sutures at a minimum include, but are not limited to:

7.2-95-1
Ethilon 4/0 W 1612T NDL.
7.2-95-2
7.2-95-3
Mersilk 4/0 W 329 NDL.
7.2-95-4
Vicryl 5/0 W 9106 NDL.
NA = Not Applicable
41

Item
Code
7.0
Standards
Review II
Date:
Yes
No
Comments

7.2-96
Suture tray, disposable.

7.2-97
Syringes with needles, disposable, sizes include, but are not

limited to:
7.2-98
SCORE:
Review I
Date:
Yes
No
7.2-97-1
2 cc 20 gauge, 1 inch.
7.2-97-2
7.2-97-3
7.2-97-4
Insulin, 50 unit/cc.
Syringes disposable, sizes include, but are not limited to:

7.2-98-1
5 cc.
7.2-98-2
10 cc.
7.2-98-3
20 cc.
7.2-98-4
50 cc.
7.2-99
Tape measure.
7.2-100
Test strips at a minimum include, but are not limited to:
7.2-101
7.2-101-1
Strips for glucose in blood, 25s

(HAEMOGLUKOTEST).
7.2-101-2
Multistix.
7.2-101-3
Strips for glucose in urine 25s (KETODIABUR

TEST).
7.2-102
Thermometer, probe cover, disposable.
7.2-103
Thermometer/temperature gauge, fridge.
7.2-104
Tongue blades, non-sterile.
7.2-105
Towel, polyethylene, disposable.
NA = Not Applicable
4242

Item
Code
7.0
SCORE:
43
Review II
Date:
Yes
No
Comments

7.2-106
Urinals.
7.2-107
Urinary drainage bag.
7.2-108
Paper rolls for stretcher, disposable (e.g., Vanco).
7.2-109
7.3
Review I
Date:
Yes
No
Standards
Vaseline gauze, sizes include, but are not limited to:

7.2-109-1
inch x 72 inch.
7.2-109-2
3 inch x 18 inch.
7.2-110
Water for irrigation, 2,000 cc, sterile.
7.2-111
Wrench adjustable metal type to open all cylinder sizes.
7.2-112
Adhesive remover (e.g., Whisk).

quantity of linen supplies (disposables are preferable where available). At a
minimum supply includes, but is not limited to:
7.3-1
Bed sheets.
7.3-2
Blankets.
7.3-3
Pillows.
7.3-4
Pillow cases.
7.3-5
Plastic cover for pillows.
7.3-6
Face cloths.
7.3-7
Bath towels.
7.3-8
Patient gowns.
7.3-9
Linen hamper/container.
7.3-10
Linen hamper/container bags.

NA = Not Applicable
43

Item
Code
Review I
Date:
Yes
No
Standards
7.0
7.4
adequate storage facilities available (steel cabinet, cupboards and shelves)
to properly/safely store materials and supplies and free the floor from
clutter.
7.5
Where shelves are used, they are off floor level and 18 inches clear of the
ceiling.
7.6
There is evidence that an inventory system is in place.
7.7
There are no expiry items on the shelves.
8.0
PHARMACEUTICAL SERVICES
8.1
a drug formulary. This formulary shall contain a wide spectrum of drugs
enabling patients to be treated for minor ailments, emergencies, and
stabilization prior to transfer to definitive medical care facility. The
selection of drugs and quantity for each drug category depends on the
facilitys operational needs and it is determined by the responsible
physician. At a minimum drugs include, but are not limited to:
8.1-1
SCORE:
Comments
Analgesic (non-narcotic) agents at a minimum include, but

are not limited to:
8.1-1-1
8.1-2
Review II
Date:
Yes
No
Oral analgesic/antipyretic tablets (e.g.,

acetaminophen).
8.1-1-2
Oral analgesic/anti-inflammatory, non-steroidal

anti-inflammatory drug (NSAID), tablets/capsules.
8.1-1-3
Injectable analgesic/anti-inflammatory, NSAID.
8.1-1-4
Analgesic topical cream and/or ointment.
Muscle relaxant, tablets.

NA = Not Applicable
4444

Item
Code
8.0
8.1-3
Urinary tract infection (UTI), analgesic/anesthetic agents, oral

tablets/capsules.
8.1-4
Antibiotic agents at a minimum include, but are not limited

to:
8.1-6
8.1-7
8.1-8
45
Review II
Date:
Yes
No
Comments
PHARMACEUTICAL SERVICES (Cont.)
8.1-5
SCORE:
Review I
Date:
Yes
No
Standards
8.1-4-1
Oral antibiotic agent tablets/capsules.
8.1-4-2
Topical antibiotic ointment for cuts, scrapes,

abrasions, insect bites, scratches, etc.
8.1-4-3
Topical antibiotic ointment for burns.
Antacid oral agents at a minimum include, but are not limited

to:
8.1-5-1
Antacid chewable tablets.
8.1-5-2
Antacid suspension.
Gastric (stomach) acid control agents at a minimum include,

Not applicable for category C facility.
8.1-6-1
Oral H2 blocker, tablets.
8.1-5-2
Injectable H2 blocker (IV and/or IM use).
Antispasmodic agents at a minimum include, but are not

limited to:
8.1-7-1
Oral antispasmodic, tablets.
8.1-7-2
Injectable antispasmodic, IM, IV.
Antiemetics (treat nausea and vomiting) agents at a minimum

8.1-8-1
Oral antiemetic, tablets.
8.1-8-2
Injectable antiemetic, vial.
NA = Not Applicable
45

Item
Code
8.0
SCORE:
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

8.1-9
Antidiarrheal oral agent, capsules.
8.1-10
Antiparasitic chewable tablets.

8.1-11
Laxative oral tablets/liquid.
8.1-12
Bronchodilators agents at a minimum include, but are not

limited to:
8.1-12-1
Nebulizer aerosol delivery solution.
8.1-12-2
Inhalers.
8.1-13
Stimulant (crushable ampule, respiratory stimulant for

inhalation only).
8.1-14
Beclomethasone disproportionate, oral inhalation agent. Not

applicable for category C facility.
8.1-15
Nasal agents at a minimum include, but are not limited to:

8.1-15-1
Antihistamine nose drops and/or spray.
8.1-15-2
Anti-infective steroid combination drops.
8.1-16
Nasal decongestant tablets/capsules.
8.1-17
Beta Blocker agent, tablets.

8.1-18
Antitussive (cough suppressant) agent, syrup, bottle.
8.1-19
Antihistamine agents at a minimum include, but are not

limited to:
8.1-19-1
Oral, tablets/capsules.
8.1-19-2
Injectable to relieve severe allergic reaction(s).
NA = Not Applicable
46
46

Item
Code
8.0
Comments
Steroidal anti-inflammatory agents at a minimum include, but

are not limited to:
8.1-20-1
Oral steroid, tablets.
8.1-20-2
Injectable steroid, IV and/or IM use.
8.1-21
Anticonvulsants (no-ncontrolled) agent, IV and/or IM use;

8.1-22
Anticoagulant, vial.
8.1-23
Vasodilator (Nitrate) agent, sublingual, tablets.
8.1-24
Antidiabetic (diabetes control) agents at a minimum include,

8.1-24-1
Oral glucose powder.
8.1-24-2
Injectable dextrose 50%, prefilled syringe.
8.1-24-3
Injectable antihypoglycemic agent (glucagon).
8.1-24-4
Injectable hyperglycemic agents (insulin).
8.1-24-5
47
Review II
Date:
Yes
No

8.1-20
SCORE:
Review I
Date:
Yes
No
Standards
8.1-24-4-1
Insulin Regular 100 U/ml 10 ml vials.
8.1-24-4-2
Insulin Human Isophane suspension.

Not applicable for category C
facility.
Oral hypoglycemic tablets (glucophage).

NA = Not Applicable
47

Item
Code
8.0
Review II
Date:
Yes
No
Comments

8.1-25
Ophthalmic agents at a minimum include, but are not limited

to:
8.1-25-1
8.1-26
8.1-27
SCORE:
Review I
Date:
Yes
No
Standards
Antibiotic ophthalmic agents at a minimum

8.1-25-1-1
Eye drops.
8.1-25-1-2
Eye ointment.
8.1-25-2
Antihistamine eye drops.
8.1-25-3
Anesthetic eye drops.
8.1-25-4
Diagnostic agents eye drops, Myotic/Mydriatic

(e.g., Pilocarpine HCL-2%).
8.1-25-5
Other eye drops (i.e., irrigation, dry eye, eye wash).
Anesthetic agents at a minimum include, but are not limited

to:
8.1-26-1
Injectable local anesthetic solution.
8.1-26-2
Topical local anesthetic ointment, tube.
8.1-26-3
Oral (gel) local anesthetic, bottle.
Vaccination agents at a minimum include, but are not limited

to:
8.1-27-1
Tetanus immunoglobulin, IM use.
8.1-27-2
Tetanus toxoid, IM use.
NA = Not Applicable
48
48

Item
Code
8.0
Comments
Intravenous (IV) fluids at a minimum include, but are not

limited to:
8.1-28-1
Dextrose infusion, bag.
8.1-28-2
Lactate Ringer (LR) infusion.
8.1-28-3
Sodium Chloride (NS) infusion.
8.1-29
Rehydration oral agent, sachet.
8.1-30
Diuretics (treat water retention) agents at a minimum

8.1-31
49
Review II
Date:
Yes
No

8.1-28
SCORE:
Review I
Date:
Yes
No
Standards
8.1-30-1
Oral diuretic, tablets.
8.1-30-2
Injectable diuretics.
8.1-30-3
Infusable diuretic solution, bag.
External/topical agents at a minimum include, but are not

limited to:
8.1-31-1
Antibiotic-anesthetic-steroid, hemorrhoidal,
ointment/cream.
8.1-31-2
Corticosteroid topical cream, tube.
8.1-31-3
Antipruritic topical cream and/or lotion, tube

and/or bottle, as applicable.
8.1-31-4
Antifungal topical cream, solution and/or powder.
8.1-31-5
Antiseptic cleanse/scrub topical solution, bottle.
8.1-31-6
Antiseptic cleanser/scrub (i.e., surgical hand scrub,

antiseptic skin cleanser).
NA = Not Applicable
49

Item
Code
8.0
8.1-33
Comments
8.1-31-7
Antiseptic topical solution (i.e., isopropyl alcohol,

betadine, povidone-iodine, etc.).
8.1-31-8
Antiseptic swab (alcohol sachet).
8.1-31-9
Emollient/lubricant, white petroleum KY jelly, tube.
8.1-31-10
Otic drops (cleanser ear drops).
Diluents agents at a minimum include, but are not limited to:

8.1-32-1
Sodium Chloride (NS), 10/20 ml ampules.
8.1-32-2
Sterile water for injection, 10/20 ml ampules.
Miscellaneous agents at a minimum include, but are not

limited to:
8.1-33-1
Adhesive remover for surgical/regular tape or

dressing removal.
8.1-33-2
Silver nitrate applicators.
8.1-33-3
Throat lozenges.
8.1-33-4
Glycerin bottle.
DRUG ADMINISTRATION - Every proponent organization shall ensure

that their medical facilities have a drug dispensing guideline s (written in a
clear format) for nurses who are authorized to administer and dispense
certain drugs in the absence of a physician and at a minimum it include
the following:
8.2-1
SCORE:
Review II
Date:
Yes
No
8.1-32
8.2
Review I
Date:
Yes
No
Standards
A list of all medications/drugs that clearly stipulate which

medications can be administered by the nurse as standing
order (SO) or routine order (RO), and which ones require a
physicians consultation telephone order (TO).
NA = Not Applicable
50
50

Item
Code
8.0
8.3
8.2-2
Standing order guidelines for nurses.

8.2-3
Specific procedures to be followed for all TOs including

documentation process.
8.2-4
Specific criteria for privileging nurses to administer and dispense

medications listed in the drug formulary and to administer the
drugs in the emergency response bag. At a minimum:
Comments
8.2-4-1
There is evidence that the nurse successfully

completed a drug familiarization competency
program.
8.2-4-2
There is a drug information reference system

available on-site or remotely (e.g., physician/
pharmacist consultation/online drug information
site/drug inserts file/pharmacology book).
DRUG STORAGE - Every proponent organization shall ensure that their

medical facilities have an adequate storage and inventory control system
with appropriate checklists in place to facilitate the dispensing and
inventory control of all medications/drugs in stock, as follows:
8.3-2
51
Review II
Date:
Yes
No
8-3-1
SCORE:
Review I
Date:
Yes
No
Standards
Ensure that all drugs/medications listed are:

8.3-1-1
Available.
8.3-1-2
Current.
8.3-1-3
Within the minimum stock level.
8.3-1-4
Rotated (arrange the shorter expiry date in front).
Inventory/expiration check date is conducted on monthly basis.

Log is available upon request.
NA = Not Applicable
51

Item
Code
8.0
SCORE:
Review II
Date:
Yes
No
Comments

8.3-3
8.4
Review I
Date:
Yes
No
Standards
All medications/drugs shall be stored according to

manufacturer's recommendations, as follows:
8.3-3-1
In an air conditioned room.
8.3-3-2
On shelves above floor level or in a lockable

cupboard.
8.3-3-3
Appropriately organized and identified in a

systematic way (alphabetic order or drug group).
8.3-3-4
Medications for external use are stored separately

from oral medications.
8.3-3-5
Narcotics/controlled substances, if available, are

stored under double lock.
8.3-3-6
Temperature sensitive drugs are stored in a dedicated

fridge as fallows:
8.3-3-6-1
Temperature is maintained at 2 to 8
Celsius (C) [36-45 Fahrenheit (F)].
8.3-3-6-2
Temperature is monitored and

recorded twice daily.
8.3-3-6-3
Fridge is cleaned twice a month.
DRUG DISPENSING - Every proponent organization shall ensure that their

medical facilities dispense all medications/drugs as follows:
8.4-1
In a suitable container.
8.4-2
At a minimum, labeled with the following information:

8.4-2-1
Patients name and ID number.
8.4-2-2
Date.
NA = Not Applicable
5252

Item
Code
8.0
8.5
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments

8.4-2-3
Drugs name and strength.
8.4-2-4
Dispensing instructions (e.g., one (1) tablet three

times a day after meals).
DRUG DISPOSAL - Every proponent organization shall ensure that their

medical facilities have a system in place for the safe disposal of expired
drugs and it is implemented as follows:
8.5-1
8.5-2
Expired medications/drugs are handled as follows:

8.5-1-1
Placed into a box.
8.5-1-2
Box is labeled expired.
8.5-1-3
Stored separately from other medications/drugs.
There is evidence that expired medications/drugs were sent to

supplier for proper disposal or other disposal system that meets
MOH regulations. Documentation is available upon request.
8.6
Every proponent organization shall ensure that their medical facilities staff
is familiar with and adhere to MOH regulations in regards to
transportation, dispensing, administration and disposal of
Narcotics/Controlled substances, where applicable.
9.0
SUPPORT SERVICES
Ambulance Service
9.1
SCORE:
53

provide, or make arrangements to provide, a dedicated emergency vehicle
(ambulance) to transport the sick and injured to a hospital facility for
further management.
NA = Not Applicable
53

Item
Code
9.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
SUPPORT SERVICES (Cont.)
Ambulance Service
9.2
Every proponent organization shall ensure that their ambulance is a twowheel or four-wheel (2WD/4WD) drive vehicle depending on location and
terrain condition (e.g., tracks, dirt roads, etc.).
9.3
Every proponent organization shall ensure that every ambulance is fully

equipped with adequate supplies and other necessities. At a minimum
these include, but are not limited to:
SCORE:
9.3-1
Proper warning flashlights.
9.3-2
Purpose markings as follows:

9.3-2-1
Red Crescent Insignia.
9.3-2-2
Ambulance signs painted on the outside.
9.3-3
Air conditioning unit in the patient compartment.
9.3-4
Fire extinguisher ABC, small type.
9.3-5
Appropriate communication device (radio, cellular and/or satellite

phone) with available network and appropriate frequency.
9.3-6
Ambulance essential medical emergency and resuscitation

supplies at a minimum include, but are not limited to:
Some items have been included as additional in order to backup
the emergency response bag supplies. The items marked with an
*asterisk, are loaded-up at the time of dispatch.
9.3-6-1
*Emergency Response Bag.
9.3-6-2
*Automated External Defibrillator (AED).
NA = Not Applicable
54
54

Item
Code
9.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Ambulance Service
9.3-6-3
SCORE:
55
*Suction machine (portable) with the following

accessories:
9.3-6-3-1
Suction catheters.
9.3-6-3-2
Tubing.
9.3-6-4
Stretcher collapsible (Ferno or other).
9.3-6-5
Backboard short with straps.
9.3-6-6
Long board short with straps (van type only).
9.3-6-7
Kendrick Extrication Device (KED).
9.3-6-8
Hare traction.
9.3-6-9
Oxygen cylinder, large size (modular and van type

only).
9.3-6-10
Portable oxygen resuscitation unit (e.g., Robert Shaw

unit or other).
9.3-6-11
At a minimum, the following oxygen supplies

accessories are available:
9.3-6-11-1
Rebreathing mask.
9.3-6-11-2
Nasal cannulas.
9.3-6-11-3
Tubing.
9.3-6-12
Oxygen cylinder key.
9.3-6-13
Rigid cervical collar, sizes as follow:

9.3-6-13-1
Small.
9.3-6-13-2
Medium.
9.3-6-13-3
Large.
NA = Not Applicable
55

Item
Code
9.0
Standards
Review I
Date:
Yes
No
Review II
Date:
Yes
No
Comments
Ambulance Service
9.3-6-14
First aid supplies as follows:

9.3-6-14-1
9.3-6-15
SCORE:
First aid kit - unit size 36.

For more information, see
Attachment 23, page 140.
9.3-6-14-2
Ace bandages.
9.3-6-14-3
Kerlix.
9.3-6-14-4
Cold packs.
9.3-6-14-5
Scissors.
Infection/Environmental control items and Personal

Protective Equipment (PPE) include, but are not
limited to:
9.3-6-15-1
Goggles.
9.3-6-15-2
Surgical mask.
9.3-6-15-3
Plastic apron.
9.3-6-15-4
Examination gloves (sterile).
9.3-6-15-5
Examination gloves (unsterile).
9.3-6-15-6
Small sharps container.
9.3-6-15-7
Infectious waste plastic bag.
9.3-6-15-8
Plastic trash bag.
9.3-6-15-9
Heavy duty gloves.
9.3-6-15-10
Safety hard hat.
9.3-6-15-11
Safety shoes.
NA = Not Applicable
5656

Item
Code
9.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Ambulance Service
9.3-6-16
9.4
9.5
9.6
9.7
Miscellaneous items include, but are not limited to:

9.3-6-16-1 Notepad.
9.3-6-16-2 Pen.
9.3-6-16-3 Flash light, 9 volt.
9.3-6-16-4 Tire gauge.
9.3-6-16-5 Kleenex tissue.
9.3-6-16-6 Safety triangle.
Every proponent organization shall ensure that their ambulances
equipment and supplies are checked daily, weekly or after each patient
trip. Inspections are recorded and available upon request.
Every proponent organization shall ensure that their ambulance(s) is taken
for a test run on a daily basis. The vehicle condition is checked and
recorded and available upon request.
Every proponent organization shall ensure that their ambulance(s) is
thoroughly cleaned inside and washed outside on a weekly basis or after a
patient run, if necessary.
Every proponent organization shall ensure that their ambulance(s) have
periodic maintenance (quarterly) and required Government road test.
Documentation evidence is available upon request.
Communications
9.8
a communication book/file available to staff to maintain effective internal
and external communication.
9.9
a notice board(s) available and that it contain current relevant information,
e.g., safety, infection control, etc.
SCORE:
57
NA = Not Applicable
57

Item
Code
9.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Communications
9.10
9.11
9.12
9.13
9.14
Every contractor company shall ensure that their medical facilities have the
following communication devices available:
A landline phone with internal and external access, including
9.10-1
direct access to emergency services.
Global system for mobile communications (GSM) and/or other
9.10-2
communication devices with available network and appropriate
frequency for field communication.
a dedicated telephone available for internal communication and with
appropriate dial access to communicate directly with Medical Designated
Facilities (MDFs) or other agencies to request external medical assistance
and advice.
a fax machine available either in the medical facility or in a nearby
administrative office.
a dedicated emergency communication device (110 or similar), for
receiving expedient information/instructions regarding fire and/or other
disaster in the camp and/or surrounding construction area.
where applicable, have all their communication equipment checked per
shift. Findings must be documented and available upon request.
Janitorial Services
9.15
a dedicated part-time or full-time janitor on the day shift.
9.16
Every proponent organization shall ensure that their medical facilities are
cleaned inside and outside to acceptable healthcare standards.
SCORE:
NA = Not Applicable
5858

Item
Code
9.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Janitorial Services
9.17

janitor receives training/orientation in medical housekeeping. On-site
orientation performed by a nurse and/or a senior janitor is acceptable.
Evidence of completion, which lists all the items covered during the
orientation, is available upon request.
9.18

janitor attended an infection control class. On-site orientation performed
by a nurse, is acceptable. Evidence of completion, which lists all the items
covered during the orientation, is available upon request.
9.19

janitor is appropriately immunized prior to medical facility assignment.
Evidence of immunization is available upon request.
9.20

according to their size and needs have sufficient housekeeping equipment
and supplies. At a minimum these include, but are not limited to:
9.20-1
SCORE:
59
Mops of two (2) different color.
9.20-2
J Cloth.
9.20-3
Trolley with dual mop bucket and wringer or portable, bucket

with wringer for small clinic.
9.20-4
Sodium Hypochlorite (Clorox bleach).
9.20-5
Liquid soap.
9.20-6
Trigger spray bottle.
9.20-7
Detergent upgrade or similar, e.g., Beaucoup for patient area.

NA = Not Applicable
59

Item
Code
9.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Janitorial Services
9.20-8
Plastic bags for rubbish (color coded for infectious waste).
9.20-9
Paper towels for sinks and spills.
9.20-10
Paper towel dispenser.
9.20-11
Wet floor sign.
9.20-12
Blood Spill Kit.
9.20-13
Floor polish.
9.20-14
Window cleaner.
9.20-15
Furniture polish.
9.20-16
General multi-cleaner with bleach for sinks, etc.
9.20-17
Toilet bowl and urinal cleaner.
9.20-18
Waste bin, pedal type with lid for clinical waste.
9.20-19
Waste basket, general purpose.
9.20-20
Hand brush and dust pan.
9.20-21
Heavy duty rubber gloves.
9.20-22
Hand sanitizer, ethyl alcohol 70% base (Santi-gel or Septogel).
9.21

janitor closet is clean and tidy.
Not applicable for single portable facility.
9.22

cleaning agents and disinfectants are appropriately labeled and stored.
SCORE:
NA = Not Applicable
60
60

Item
Code
9.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Janitorial Services
9.23

color coded mops are cleaned and disinfected on a daily basis. Evidence is
9.24
Every proponent organization shall ensure that their medical facilities are
cleaned on a daily basis, cleaning is in evidence. At a minimum cleaning
includes, but is not limited to:
9.24-1
Damp dusting.
9.24-2
Polishing floors and/or furniture as applicable.
9.24-3
Vacuuming.
9.24-4
Mopping of floor.
9.24-5
Cleaning toilet areas.
9.25

janitors use separate cleaning equipment for toilet areas. This shall be in
evidence.
9.26
Medical facilities shall ensure that there is a regular (twice daily and as
necessary) removal of trash from all clinical areas.
9.27
a procedure for cleaning blood spills and that it is posted. This shall be in
evidence.
9.28
Janitor and other staff know/verbalize the blood spill cleaning procedures
and cleaning fluid dilution ratios, as per guidelines.
SCORE:
61
NA = Not Applicable
61

Item
Code
10.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
MEDICAL EMERGENCY, DISASTER RESPONSE AND MEDIVAC PROCEDURES
General Requirements
10.1
a quick reference Medical Emergency and Disaster Response plan
available. At a minimum, plan outlines the following information:
10.1-1
Communication chain list of key personnel and various

services (i.e., security, firefighting and support services) and
show how chain is activated (e.g., ring-down-system flow
chart). This is strategically posted (e.g., nursing station/ safety
notice board).
Role of each medical personnel in the event of medical

emergency and disaster response.
a 24 hour emergency and key personnel telephone numbers available and
that it is properly displayed in the clinic to facilitate proper/timely response
in the event of medical emergencies, disasters, transfers and Medivacs. At
a minimum list includes the following telephone numbers:
10.2-1
Company Security Operations.
10.2-2
Saudi Aramco Security Operation.
10.2-3
Police.
10.2-4
Red Crescent.
10.2-5
Nearest healthcare facilities including MOH hospitals.
10.2-6
Company designated hospitals.
10.1-2
10.2
10.2-7
10.2-8
10.2-9
SCORE:
On-call company representative or alternate (construction

Manager/Admin Manager/Health or Safety Advisor).
Trained first aiders in charge of first aid kits, available and
displayed.
Evacuation group leader, where applicable.
NA = Not Applicable
62
62

Item
Code
10.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
MEDICAL EMERGENCY, DISASTER RESPONSE AND MEDIVAC PROCEDURES (Cont.)
10.3
10.4
SCORE:
63
Every proponent organization shall ensure that their medical facilities at a

minimum have the following emergency response bag(s) available:
10.3-1
At least two (2) bags in Category A and B facilities.
10.3-2
At least one (1) bag in Category C facilities.
emergency response bag(s) have the required medical supplies. The
contents of each bag include, but are not limited to:
10.4-1
NURSE SUPPLIES at a minimum include, following items:
10.4-1-1
Sphygmomanometer.
10.4-1-2
Stethoscope.
10.4-1-3
Paramedic shears (scissors).
10.4-1-4
Penlight.
Disposable gloves at a minimum include, the
10.4-1-5
following sizes:
10.4-1-5-1 Medium, unsterile.
10.4-1-5-2 Large, unsterile.
10.4-1-6
Masks.
10.4-1-7
Paper bag, waxed.
10.4-1-8
Sharps container, small.
INTRAVENOUS (IV) SUPPLIES at a minimum include, the
10.4-2
following items:
10.4-2-1
Lactated ringers (LR), 1,000 cc, bag.
10.4-2-2
Normal saline (9NS), 1,000 cc, bag.
10.4-2-3
Dextrose 5%, 500 cc, bag.
10.4-2-4
Adhesive tape, 1 inch.
NA = Not Applicable
63

Item
Code
10.0
Standards
Review I
Date:
Yes
No
Review II
Date:
Yes
No
Comments
10.4-2-5
10.4-3
SCORE:
IV administration (giving) sets at a minimum

includes, the following:
10.4-2-5-1
5 drop set.
10.4-2-5-2
6 drop set.
10.4-2-6
Alcohol swabs.
10.4-2-7
IV cannulas (catheters) at a minimum include

but are not limited to, the following sizes:
10.4-2-7-1
14 gauge.
10.4-2-7-2
16 gauge.
10.4-2-7-3
18 gauge.
10.4-2-7-4
20 gauge.
10.4-2-7-5
22 gauge.
10.4-2-8
Band aids.
10.4-2-9
Tourniquets, 1 inch and/or inch.
10.4-2-10
Tegaderm, 6 cm x 7cm.
10.4-2-11
Gauze sponges 2 x 2, sterile.
AIRWAY SUPPLIES (PATIENT SUPPLIES) at a minimum

include, the following items:
10.4-3-1
Ambu bag (BVM), adult.
10.4-3-2
Oral airway adult, at a minimum includes, the

following sizes:
10.4-3-2-1
Small (3).
10.4-3-2-2
Medium (4).
10.4-3-2-3
Large (5).
NA = Not Applicable
6464

Item
Code
10.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
10.4-3-3
10.4-4
SCORE:
65
Laryngeal masks at a minimum include, the

following sizes:
10.4-3-3-1
Small.
10.4-3-3-2
Medium.
10.4-3-3-3
Large.
10.4-3-4
Bandage, 1 inch.
10.4-3-5
Syringe, 10 cc.
10.4-3-6
Pocket mask, adult.
10.4-3-7
Oxygen masks with reservoir (non-rebreather),

adult.
10.4-3-8
Nasal cannula.
10.4-3-9
Suction connecting tubing.
10.4-3-10
Suction catheter, size 14 french/Yankauer.
DRESSINGS/BANDAGES SUPPLIES (PATIENT SUPPLIES) at

a minimum include, the following items:
10.4-4-1
Multi-trauma dressing, sterile.
10.4-4-2
Abdominal pad, sterile.
10.4-4-3
Gauze sponges at a minimum include, the

following sizes:
10.4-4-3-1
2 x 2, sterile.
10.4-4-3-2
4 x 4, sterile.
10.4-4-4
Vaseline gauze, 3 inch x 18 inch.
10.4-4-5
Triangular bandage.
10.4-4-6
Kerlix roll.
NA = Not Applicable
65

Item
Code
10.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
10.4-4-7
10.4-4-8
10.4-4-9
10.4-4-10
10.4-4-11
10.4-4-12
10.4-4-13
10.4-5
SPLINTS, DISPOSABLE (PATIENT SUPPLIES) at a minimum

include, the following sizes:
10.4-5-1
10.4-5-2
10.4-6
Short.
Long.
BURN SUPPLIES(PATIENT SUPPLIES) at a minimum include,

the following items:
10.4-6-1
Sterile burn sheets, disposable.
10.4-6-2
Burn pads sterile.
10.4-6-3
Surgical face masks, disposable.
10.4-6-4
10.4-6-5
SCORE:
Ace wraps at a minimum include, the following

sizes:
10.4-4-7-1
4 inch.
10.4-4-7-2
6 inch.
Non-adhesive dressing.
Micropore roll, 1 inch.
Povidine iodine swabs.
Ice pack.
Bacitracin ointment, tube.
Band aids.
Sterile gloves at a minimum include, the

following sizes:
10.4-6-4-1
6.5.
10.4-6-4-2
7.0.
10.4-6-4-3
8.0.
Disposable gowns.
NA = Not Applicable
66
66

Item
Code
10.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
10.4-7
SCORE:
67
EMERGENCY DRUGS FOR EMERGENCY RESPONSE BAG at

a minimum include, the following drugs:
Staff must be certified competent to administer these drugs.
10.4-7-1
Adenosine 6 mg/2 ml ampule.

10.4-7-2
Amiodarone injection, 150 mg/3 ml ampule.

10.4-7-3
Atropine sulphate 1 mg/0 ml pre-filled syringe.

10.4-7-4
Albuterol inhaler, 200 inhalations inhaler.
10.4-7-5
Calcium chloride 10%, 1 gm/10 ml pre-filled

syringe.
10.4-7-6
Diphenhydramine 50 mg/1 ml vial.
10.4-7-7
Dopamine infusion 200 mg/5 ml vial.

10.4-7-8
Dextrose 50% injection, 50 ml pre-filled syringe.

10.4-7-9
Epinephrine 1: 1,000, 1 mg/1 ml.
10.4-7-10
Epinephrine 1: 10,000, 1 mg/10 ml pre-filled

syringe.
10.4-7-11
Glucose powder, oral, bottle.
NA = Not Applicable
67

Item
Code
10.0
Standards
Review I
Date:
Yes
No
Review II
Date:
Yes
No
Comments
SCORE:
10.4-7-12
Glucagon injection.
10.4-7-13
Hydrocortisone injection, 100 mg/2 ml vial.

10.4-7-14
Inderal (propanolol) ampule.

10.4-7-15
Magnesium sulphate injection, 1 gm/2 ml

ampule.
10.4-7-16
Nitroglycerin tablets, 0.4 mg, bottle.
10.4-7-17
Nitroglycerin 50 mg vial.
10.4-7-18
Normal saline, 10 ml, ampule.
10.4-7-19
Sodium bicarbonate 50 mEq/50 ml, pre-filled

syringe.
10.4-7-20
Vasopressin injection, 20 units/ml vial.

10.4-7-21
Xylocard 2%, 20 mg/ml, abboject.
10.4-7-22
Xylocard 20%, 200 mg/ml, abboject (for

dilution).
10.4-7-23
Xylocaine spray 10%.

10.4-7-24
Xylocaine injection (10 mg per 2 ml), 20 ml

multidose vial.
NA = Not Applicable
6868

Item
Code
10.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
10.5
10.6

emergency response bag(s) are appropriately checked as follows: Evidence
of completion is available upon request.
10.5-1
On monthly basis and/or after use.
10.5-2
Quantity is checked and recorded.
10.5-3
Validity is checked and recorded.
Every proponent organization must ensure that staff has periodic disaster
training as follows:
10.6-1
Training includes the application of a commonly used triage

system (e.g., Simple Triage and Rapid Transport (S.T.A.R.T.);
Move, Assess, Sort and Send (M.A.S.S.) in disaster
management.
10.6-2
Training is conducted yearly. Evidence of completion is

10.6-3
Staff takes part in at least two (2) disaster drills a year.
10.6-4
Completion of training both theoretical and practical is

documented on the staffs training record. Evidence is
11.0
QUALITY IMPROVEMENT REQUIEMENTS
11.1
a quality improvement study in progress. Evidence is available upon
request.
SCORE:
69
NA = Not Applicable
69

Item
Code
Review I
Date:
Yes
No
Standards
12.0
PATIENT PROCESSING AND MEDICAL RECORDS
12.1
dedicated medical record/file available for the following individuals:
12.2
12.1-1
For every employee as stipulated in article 136 of the Saudi

Labor and Workmen Law.
12.1-2
For every patient.
Comments

document each and every encounter into the medical record. At a
minimum, the following information is included:
12.2-1
Patients name and ID number.
12.2-2
Date of visit.
12.2-3
Time in and time out.
12.2-4
History.
12.2-5
Examination and assessment results.
12.2-6
Diagnosis or impression.
12.2-7
Treatment given, medications, etc.
12.2-8
Discharge status/sick leave/work restriction/referral.
12.2-9
Discharge instructions.
12.2-10
Significant Medical Data Sheet (SMDS), i.e.,

ordinary/occupational/work injuries.
12.3
a tetanus immunization record available in the patients medical
record/file.
12.4

record all injuries in a log book. Evidence is available upon request.
SCORE:
Review II
Date:
Yes
No
NA = Not Applicable
7070

Item
Code
12.0
12.5
12.6
13.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
PATIENT PROCESSING AND MEDICAL RECORDS (Cont.)

a process available (e.g., log book) for documenting patients attendance.
Information listed is generally nonclinical and is kept for statistics purposes
and for periodic report to management.
a process available for requesting medical aid and for reporting patient
off-duty status.
HEALTH CARE POLICIES, PROCEDURES AND GUIDELINES - For more information, see Attachment 25, page 145.
General Guidelines
13.1
13.2
Every proponent organization shall ensure that their policies and

procedures are accessible to all staff.
Staff knows/verbalize the location of their medical facilitys policies and
procedures.
Scope of Service Policies and Procedures

13.3
Every proponent organization shall ensure that each of their medical

facilities has a policy that defines their scope of service offered as follows:
13.3-1
Type of care and treatment offered at the facility.
13.3-2
Eligibility of service.
Investigations, specialized tests and clinical procedures
13.3-3
(diagnostic or otherwise) performed in the facility.
13.3-4
Hours of operation.
Administrative - Manpower Requirements Policies and Procedures

13.4
SCORE:
71
MANPOWER REQUIREMENTS GUIDELINES - Every proponent

organization shall have a policy stating the criteria (influencing factors)
used by the organization to determine its manpower requirements to
ensure that their medical facilities have adequate coverage at all times.
NA = Not Applicable
71

Item
Code
13.0
Standards
Review I
Date:
Yes
No
Review II
Date:
Yes
No
Comments
HEALTH CARE POLICIES, PROCEDURES AND GUIDELINES (Cont.)
Infection Control Policies and Procedures

13.5
13.6
SCORE:
INFECTION CONTROL GUIDELINES at a minimum include, the

following policies and procedures:
13.5-1
Infection Control in Medical Facility Personnel.
13.5-2
Blood and Infectious Fluid Exposure.
13.5-3
Employee Screening and Immunization Program.
13.5-4
Hand Hygiene.
13.5-5
Handling of Soiled and Clean Linen.
13.5-6
Specimen Collection and Transport, where applicable.
13.5-7
Cleaning of Spills.
13.5-8
Sharp Injuries, what to do in the event and reporting.
13.5-9
Reporting Occupational Illness/ Communicable diseases (i.e.,

Hepatitis B/C, Tuberculosis, Chicken pox, etc.).
GENERAL POLICIES AND PROCEDURES at a minimum include, the

following policies and procedures:
13.6-1
Waste Management.
13.6-2
Every proponent organization has a patient consultation,

referral and transfer policy to Saudi Aramco remote urgent
care facilities.
Contractor shall comply with RAC OM-10.
13.6-3
Every proponent organization shall ensure that their medical

facilities have a policy that describes a reliable alternative
system of transfer in place in the absence of an ambulance.
13.6-4
Every proponent organization shall ensure that a policy on

Occupational Health Services (physicals and conservation
program, i.e., hearing, pulmonary, etc.) is available for their
employees.
NA = Not Applicable
72
72

Item
Code
13.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Patient care Policies and Procedures

13.7
SCORE:
PATIENT CARE GUIDELINES (Examination and Treatment Protocol for

Nurses), at a minimum include, the following policies and procedures:
For information in how to develop your own guidelines, see
Attachment 18, page 124.
13.7-1
Protocols for the treatment of common illness and

emergencies, from a common cold to chest pain, snake bites,
burns, etc.
13.7-2
Protocols for (steps to follow) for consultation and for patient

referral to the nearest hospital, or to an inpatient medical
facility.
13.7-3
Nursing Procedures and Work Practice.
13.7-4
Management of Death.
13.7-5
Patient and Family Rights.
13.7-6
Confidentiality of Patient Information.
13.7-7
Medication guidelines at a minimum include, the following

policies and procedures:
13.7-8
13.7-8-1
Medication Requisition.
13.7-8-2
Prescribing, administration and dispensing of

drugs/medication in the absence of a physician or
pharmacist, in accordance with MOH regulation.
13.7-8-3
Storing Drugs.
13.7-8-4
Shipping and Receiving of Drugs.
13.7-8-5
Disposal of Drugs.
13.7-8-6
Prescription storage and administration of

narcotics and controlled drugs.
NA = Not Applicable
73
73

Item
Code
13.0
Review I
Date:
Yes
No
Standards
Review II
Date:
Yes
No
Comments
Medical Emergency and Disaster Response/Medivac Guidelines

13.8
MEDICAL EMERGENCY AND DISASTER RESPONSE/MEDIVAC

GUIDELINES at a minimum include, the following policies and
procedures:
Medical Evacuation (Medivac) for medical/traumatic
emergencies from Saudi Aramco Aviation.
13.8-1
Compliance to Saudi Aramco GI-1321.015.
13.8-2
Medical Emergency(s) Response.
13.8-3
Disaster Response.
Safety Policies and Procedures

13.9
SAFETY GUIDELINES at a minimum include, the following policies and

procedures:
13.9-1
Fire Drills and Fire Response.
13.9-2
Equipment Maintenance
13.9-3
Adherence to GI-150.002 (First Aid Training for Employees).
14.0
GENERAL REGULATIONS
14.1
printed education materials/posters available.
SCORE:
NA = Not Applicable
7474
REMOTE AREA URGENT CARE FACILITIES

Level A, B and C Facilities
Final Remarks/Recommendations:
Visit 1
Visit 2
Name of Reviewer:
___________________________________________________________________________________________________
Signature and Date:
___________________________________________________________________________________________________
SCORE:
75
NA = Not Applicable
75
Section 4 Survey and Compliance Review Report for Category D Facilities

General and Specific Minimum Standards Requirements Category/Level D Facilities (First Aid Provisions, Supplies and Training)
Item
Code
1.0
Review I
10/12/08
Yes
No
Standards
Review II
10/12/08
Yes
No
Comments
FIRST AID PROVISION IN REMOTE AREAS
A. General Regulations
1.A.1
1.A.2
1.A.3
SCORE:
Every proponent organization shall comply with the relevant articles and
regulations specified in Chapter 7 of Saudi Labor and Workmen Law and
the medical section of Saudi Aramco (SA) Safety Manual. At a minimum
this includes, but is not limited to:
Every contractor company, which operates within Saudi
Aramco remote area work sites and employs less than fifty
1.A.1-1
(50) laborers, shall provide a first aid kit/cabinet at the
worksite in strategic location(s). A first aid kit as described in
Saudi Aramco GI 150.002 is acceptable.
Provide a first aid kit/cabinet at the work site in strategic
1.A.1-2
locations.
Provide a certified first aid/BLS attendant on duty 24 hours a
1.A.1-3
day, seven days a week (24/7) as custodian.
Every proponent organization shall ensure that at least one (1) crew
member per shift has the basic level of medical care awarded by a
recognized training program (Saudi Red Crescent Society or Saudi Aramco
Health Promotion Unit as applicable). At a minimum training includes,
but is not limited to:
For more information, see Saudi Aramco GI-150.002.
1.A.2-1
1.A.2-1-1
1.A.2-2
First Aid (FA).
1.A.2-2-1
Every proponent organization shall ensure that staff in their medical
facilities attends a BLS/First Aid refresher class every two (2) years.
Evidence is available upon request.
NA = Not Applicable
7676

Item
Code
1.0
Review I
10/12/08
Yes
No
Standards
Review II
10/12/08
Yes
No
Comments
FIRST AID PROVISION IN REMOTE AREAS (Cont.)
B. First Aid Requirements

1.B.1
Every proponent organization in this category shall ensure that where

work is performed in multiple locations more than 300 meters (1,000 feet)
apart, a separate first aid kit/first aid cabinet is available for every group of
10 (ten) workers.
1.B.2
Every proponent organization in this category shall ensure that their first
aid cabinet where applicable, is as follows:
1.B.3
SCORE:
77
1.B.2-1
Made of hard wood or metal and be painted white.
1.B.2-2
Dimensions: no less than 85 cm long x 45 cm width x 30 cm

diameter.
1.B.2-3
Fitted with a lock.
1.B.2-4
Have the Red Crescent insignia and the words First Aid
Cabinet written on it.
1.B.2-5
Always be ready for use, restocked after each use.
1.B.2-6
Placed on a strategic location, accessible at all times.
aid kit at a minimum have the following supplies, as specified in Saudi
Aramco GI-150.002:
1.B.3-1
Bandage, compress, 5 cm.
1.B.3-2
Bandage, compress, 10 cm.
1.B.3-3
Bandage, gauze roller, 5 cm x 550 cm.
1.B.3-4
Bandage, plastic adhesive, 2.5 cm x 7.5 cm.
1.B.3-5
Bandage, triangular; sterile, 100 cm x 100 cm x 140 cm.
1.B.3-6
Cold pack.
NA = Not Applicable
77

Item
Code
1.0
Review I
10/12/08
Yes
No
Standards
Review II
10/12/08
Yes
No
Comments
1.B.4
1.B.3-7
Compress gauze, 60 cm x 180 cm.
1.B.3-8
Forceps and scissors.
1.B.3-9
Iodine PVP (polyvinyl povidone) crushable ampules.
1.B.3-10
Green soap swab, crushable; 0.5 ml; width 2 mm x 51 mm (2

inches) gauze pad.
1.B.3-11
Tourniquet supplied with a separate card to note the time

tourniquet was applied and the location of tourniquet.
1.B.3-12
First Aid Booklet, Arabic and/or English.
aid cabinet, if provided, at a minimum includes the following supplies:
1.B.4-1
SCORE:
Oral airways, sizes include, but are not limited to:

1.B.4-1-1
Medium.
1.B.4-1-2
Large.
1.B.4-2
Non-sterile examination gloves.
1.B.4-3
Sterile gloves, sizes include, but are not limited to:

1.B.4-3-1
7.5.
1.B.4-3-2
8.
1.B.4-4
Band aids.
1.B.4-5
Alcohol swabs.
1.B.4-6
Iodine swabs.
1.B.4-7
Bacitracin ointment.
NA = Not Applicable
78
78

Item
Code
1.0
Standards
Review I
10/12/08
Yes
No
Review II
10/12/08
Yes
No
Comments

1.B.4-8
1.B.4-9
SCORE:
79
Sterile gauze, sizes include, but are not limited to:

1.B.4-8-1
2 x 2 or (5 cm x 5 cm).
1.B.4-8-2
4 x 4 or (10 cm x 10 cm).
Roller gauze, sizes include, but are not limited to:

1.B.4-9-1
2 inch.
1.B.4-9-2
3 inch.
1.B.4-9-3
4 inch.
1.B.4-10
Adhesive tape, 1 inch roll.
1.B.4-11
Eye pad.
1.B.4-12
Ace bandage, sizes include, but are not limited to:

1.B.4-12-1
2 inch.
1.B.4-12-2
3 inch.
1.B.4-12-3
4 inch.
1.B.4-12-4
6 inch.
1.B.4-13
Triangular bandage.
1.B.4-14
Safety pins.
1.B.4-15
Bandage scissors.
1.B.4-16
Burn sheet.
1.B.4-17
Abdominal dressing pad, 5 inch x 9 inch.
1.B.4-18
Multi-trauma dressing pad.
NA = Not Applicable
79

Item
Code
1.0
Review I
10/12/08
Yes
No
Standards
Review II
10/12/08
Yes
No
Comments
1.B.5
1.B.4-19
Cold pack.
1.B.4-20
Ammonia inhalant.
1.B.4-21
Padded arm board.
Every proponent organization in this category shall ensure that the

following safety devices are available at work locations:
1.B.5-1
Fire blanket.
1.B.5-2
Limb splints, ready to use, various types: thigh, leg, arm, etc.
1.B.5-3
Rescue type stretcher (to move injured patients), folding, 72

inch long and 10 inch wide.
1.B.5-4
Splint Stretcher, basket type litter; 4 straps; to carry patient in

any position without danger; 24 inch width 8.5 inch height.
1.B.6
Every proponent organization in this category shall ensure that signs

indicating the location of the first aid kits/cabinets are posted.
1.B.7
Every proponent organization in this category shall ensure that there is an

inventory system in place to replenish first aid kit supplies and to monitor
expiry dates. Evidence is available upon request.
1.B.8
Every proponent organization in this category shall ensure that a patient

log must be kept by the first aid attendant to register all injuries/illness
treated.
1.B.9
Every proponent organization in this category shall ensure that personnel

working in remote areas have one (1) vehicle equipped with a well
stocked first aid kit. The vehicle must be marked to indicate it is carrying a
first aid kit.
SCORE:
NA = Not Applicable
80
80

Item
Code
1.0
Review I
10/12/08
Yes
No
Standards
Review II
10/12/08
Yes
No
Comments

1.B.10
1.B.11
SCORE:
81
Every proponent organization in this category shall ensure that the

designated vehicle is marked to indicate it is carrying a first aid kit.
Every proponent organization in this category shall ensure that the person
in charge of first aid program have the following available and posted:
Contact number (24 hours) of all first aid attendants in his
1.B.11-1
area of responsibility.
Name(s) and contact number of the nearest medical referral/
1.B.11-2
evacuation facility.
Other emergency telephone numbers to call for emergency
1.B.11-3
medical assistance including Security and Red Crescent.
NA = Not Applicable
81
REMOTE AREA URGENT CARE FACILITIES

Final Remarks/Recommendations:
Visit 1
Visit 2
Name of Reviewer:
___________________________________________________________________________________________________
Signature and Date:
____________________________________________________10/12/08__________________________________________
SCORE:
NA = Not Applicable
82
82
Section 5 Attachments and References

Table 1: List of Attachments
Attachment
Number
Title
Page
Number
Saudi Labor Law (2 pages).
84
Saudi Aramco Safety Manual, Medical Section (5 pages).
86
Government Licensure of Professional Medical Personnel (1 page).
91
Scope of Service (1 page).
92
Injury Summary (1 page).
93
Tetanus Vaccine Report (1 page).
94
Cleaning of Blood Spills (3 pages).
95
Medical Equipment Minimum Requirements (2 pages).
98
Medical Supplies Minimum Requirements (8 pages).
100
10
Linen Supplies Minimum Requirements (1 page).
108
11
Drug Formulary List Minimum Requirements (7 pages).
109
12
Ambulance Medical Equipment and Supplies Minimum Requirements (2 pages).
116
13
Vehicle (Ambulance) Condition Report/Daily Checks (1 page).
118
14
Housekeeping Equipment and Supplies Minimum Requirements (1 page).
119
15
Emergency Response Bag Minimum Requirements (2 pages).
120
16
Emergency Drugs for Emergency Response Bag Minimum Requirements (1

page).
122
17
Patient Treatment Daily Log (1 page).
123
18
Examination and Treatment Protocol (TP) for Nurses (2 pages).
124
19
Standing Orders Guidelines for Nurses (6 pages).
126
20
Staff Competency Assessment and Development (4 pages).
132
21
Employee Orientation (3 pages).
136
22
Continuing Education and Training (1 page).
139
23
First Aid Kit (4 pages).
140
24
First Aid Cabinet and Contents (1 page).
144
25
Policies and Procedures (1 page).
145
26
Floor Plan Specifications for Category C Medical Facility (1 page).
146
27
Floor Plan Specifications for Rig Medical Facility (1 page).
147
Note: Samples provided in this manual are intended to be used as a reference guide only. If
implemented, it is important that you verify that the information is up-to-date with current standards
and practices.
83
83
Saudi Labor Law

Saudi Labor and Workmen Law
Chapter 7
Protection and Social Services
Labor and Workmen Law
Articles 134-6
Article 134
The employer shall provide first aid services for the workmen in accordance with the standards to be
determined by the Minister of Labor in collaboration with the Minister of Health. If the number of his
workmen in a single location or town, or within a radius of fifteen (15) kilometers, exceeds fifty, he
shall employ a nurse who shall be familiar with first-aid services and shall be exclusively assigned to
render such services; the employer shall assign a physician to examine and treat the workmen at the
place to be provided by the employer for this purpose, and the employer shall provide them with the
medicines necessary for their treatment. The aforementioned services shall be free of charge whether
during work hours or otherwise. If in the cases mentioned above, the number of workmen exceeds
one hundred (100), the employer shall, in addition, provide them with all other means of treatment in
cases requiring treatment by specialists, or performance of surgical other operations. In case operations
are performed, as well as in cases of incurable diseases, the expenses shall be taken from the Social
Insurance Funds. The costs of treatment, medicines and hospitalizations in government or charitable
hospitals, as well as the party, who will assume such costs, shall be determined pursuant to the
decision to be made by the Minister of Labor in agreement with the Minister of Health, or to the rules
laid down in the Social Insurance Law.
However, if the number of workmen is less than fifty (50), the employer must provide the workmen
with a medical aid cabinet which shall be maintained in a good condition and shall contain the
bandages, medicines, and antiseptics to be determined by the Minister of Labor in agreement with the
Minister of Health, in order to provide the workmen with first aid.
Article 135
Every employer who employs more than fifty (50) workmen shall inform the appropriate Labor Office
of the name of the physician who he has selected to treat his workmen. In case he employs more than
one hundred (100) workmen, he shall inform the office of the names of the physicians and specialists
whom he has selected to treat his workmen, and of the names of the hospitals which he has
designated for that purpose. In both cases, he must notify the appropriate Labor Office of the
minimum number of days fixed for the examination of workmen, provided that this minimum shall not
be less than three (3) times a week.
Article 136
Every employer shall prepare for each workman a medical file showing the result of the medical
examination performed on the workman upon his employment, a description of the cases of his illness,
the stages of his treatment, and the periods of his absence from work, provided that mention shall be
made in the file of the kinds of ordinary and occupational diseases and labor injuries.
Saudi Labor Law
ATTACHMENT 1
Page 1 of 2
84
84
First Aid Facilities at Work

(Originally Published in Umm al-Qura, No. 2534 July 26, 1974)
Decision No. 404 Based on Article 245 of Labor Law
Article I
An employer who employs less than fifty (50) workmen shall provide at the work site a first aid cabinet
containing bandages, medicines, and disinfectants.
Article II
The employer shall assign one or more persons to be responsible for administering first aid to the
injured at all times during working hours, provided the person-in-charge shall be one of the
establishments employees who will either be trained in first aid procedures in accordance with a
program to be agreed upon with the Saudi Red Crescent Society, or who holds a certificate from a
hospital attesting that he has practiced first aid and is qualified to administer it.
Article III
An employer who employs fifty (50) or more laborers shall provide at the work site a first aid room which
meets the following standards:
Section (F) A licensed nurse shall be on duty at all times during working hours under the supervision of a
physician.
Article VI
An employer who employs less than fifty (50) workmen shall assign an appropriate number of his
workmen to receive first aid in accordance with Article II.
Saudi Labor Law

ATTACHMENT 1
Page 2 of 2
85
85
Saudi Aramco Safety Manual

28
Medical
28.1
Purpose
This chapter provides the minimum requirements for medical care to personnel performing work
at Saudi Aramco (SA) work locations and shall include the following services:
First Aid and Urgent Care
Medical Emergency Response, Stabilization, and Transfer to Definitive Care
Disaster Response
28.2
Scope
It covers all SA and contractor personnel operating within SA facilities, on SA job sites outside
of operating facilities, off SA property under a SA contract, and in applicable SA domestic
joint venture companies.
28.3
References
SA General Instructions:
GI 6.025, Control of Remote Area Travel and Search/Rescue Procedures
GI 1321.015, Request for Air Medical Evacuation
GI 150.002, First Aid/BLS Training and First Aid Kits
Schedule D SA Safety, Health, and Environmental Requirements Injury and Damage Reporting
First Aid Facilities
MMSR Manual - Medical Minimum Standards Requirements for Industrial Clinics Manual
28.4
Provision of First Aid/Medical Facilities

28.4.1
Saudi Aramco Proponent Organization (SAPO) and/or the contractor shall

comply, in its entity, with the first aid/medical provisions described below prior
to start of work activities. These provisions are applicable to all work activities
within SA facilities, on SA jobsites outside of operating facilities, off SA
property but under a SA contract, and in applicable SA domestic joint venture
companies.
28.4.2
First aid is the immediate help that is provided at the work location to injured
or seriously ill personnel prior to the arrival of professional medical assistance.
Saudi Aramco Safety Manual Medical Section
ATTACHMENT 2
Page 1 of 5
86
86
28.4
Provision of First Aid/Medical Facilities (Cont.)

28.4.3
Employers shall be responsible for ensuring that first aid/Basic Life Support
(BLS) trained personnel and appropriate first aid facilities are available for their
personnel at all work locations.
28.4.4
First aid facilities shall be kept in a sanitary condition and in strict compliance
with the minimum requirements specified in the Medical Minimum Standards
Requirements for Industrial Clinics Manual (MMSR) at all times.
28.4.5
First aid supplies shall be kept readily available in a first aid kit or a cabinet
designated for those supplies only.
28.4.6
A first aid attendant shall be responsible for first aid kits or cabinet and shall
ensure there is sufficient stock of all listed supplies at all times.
28.4.7
A suitable type of stretcher shall be available at all work locations.
28.4.8
Signs/notices shall be posted indicating the following:

a.
b.
c.
d.
28.5
The name of the person who is in charge of first aid kit or cabinet.
The hospital where injured/ill personnel are to be transported.
The telephone number(s) of the doctor(s) or first aid attendant(s).
The emergency telephone number(s) to be called for assistance.
28.4.9
One (1) vehicle equipped with a well-stocked first aid kit for each crew shall be
available for personnel performing pipeline and power line work or who are
working in remote areas. Vehicles shall be marked to indicate that they carry a
first aid kit. A minimum of one (1) man in every crew shall have a valid first
aid/BLS certificate (See GI 150.002).
28.4.10
A medical logbook shall be maintained at every first aid station and medical facility
by the first aid attendant/nurse who must log all injuries/illnesses treated. (Refer to
MMSR Manual for sample log.)
First Aid Attendants/Medical Professional Personnel

28.5.1
Employers, employing less than fifty (50) personnel, shall have an appropriate
number of personnel, including those in charge of the first aid kits or supply
cabinets, trained in first aid/BLS (See GI 150.002).
28.5.2
When there are more than fifty (50) personnel employed within a radius of 15
kilometers (9.4 miles), employers shall provide a first aid facility at the work location,
in accordance with the criteria set out in the MMSR Manual. As a minimum, a first
aid/BLS certified nurse shall be assigned to and in charge of the medical/first aid
facility.
28.5.3
Medical professional personnel (physicians/nurses) shall meet the licensing

requirements of the Saudi Arab Government (SAG) Ministry of Health (MOH) and
possess the necessary experience, and minimum qualifications, and required
certifications specified in the MMSR Manual.
28.5.4
Medical professional personnel shall also be provided with continuing education by

their employer as required by the MOH. This continuing education shall include, but
not be limited to: First aid/BLS, safety and infection control, and fire and disaster
training, etc.

ATTACHMENT 2
Page 2 of 5
87
87
28.6
Medical Care at Work Site

28.6.1
First aid kits/Cabinet

A.
B.
28.6.2
Employers employing less than fifty (50) personnel shall provide a first aid kit or
cabinet at the work location. Minimum requirements for first aid kits are
specified in the MMSR Manual.
A separate first aid kit or cabinet shall be provided for every group consisting of
more than 10 personnel if work is performed in multiple locations more than
300 meters (1,000 feet) apart.
Medical Facilities
A.
B.
Employers with more than fifty (50) personnel in a single location, or within a
radius of 15 kilometers (9.4 miles) shall provide, at a central work location, a
medical facility in accordance with the criteria set out in the MMSR Manual for
each of the following categories:
x
Category A (Physician operated, large).
x
Category B (Physician operated, small).
x
Category C (Nurse operated).
These facilities shall:
x
28.7
Have the capability to provide first aid urgent care, pre-hospital care and
resuscitation, stabilization, and prompt transfer to the nearest definitive
care facility.
Have an emergency response plan detailing their respective response
capabilities specific to geographical location. A medical emergency and
disaster call out list shall be posted in the facility.
Medical Facilities Requirements

28.7.1
28.7.2
Medical facilities are categorized according to the following criteria:

A.
Number of personnel at the work location.
B.
Remoteness of the work location and access to medical care.
C.
Potential risk factors at the work location.
Regardless of the assigned category, employers shall strictly comply with all
requirements set out in the MMSR Manual. These include:
A. Building specifications.
B. Scope of service.
C. Manpower requirements.
D. Staff qualifications and continuing education.
E. Equipment and supplies.
F. Medication supplies.
G. Support services (communications/ambulance services/janitorial services).
H. Medical emergency and disaster response procedures/Medivac procedures.
I.
Health care policies and procedures guidelines.

ATTACHMENT 2
Page 3 of 5
88
88
28.8
28.9
28.10
Medical Transfer
28.8.1
Employers shall provide, or make arrangements to provide, a dedicated emergency

vehicle (ambulance with purpose markings, configured safely, and equipped with
emergency and resuscitation supplies to transport injured/ill personnel to the nearest
designated health care facility. This vehicle shall be maintained in a safe, clean,
sanitary, and roadworthy condition in compliance with SAG regulations and SA
vehicle requirements.
28.8.2
Ambulances shall be equipped, as a minimum, with supplies as specified in the

MMSR Manual.
28.8.3
A daily ambulance log and ambulance preventive maintenance work sheet shall be
maintained.
28.8.4
Employers shall provide ambulance drivers with first aid and BLS training, orientation
and safety training.
28.8.5
Ambulance drivers shall have a valid SAG driving license.
Medical Evacuation (Medivac)

28.9.1
Contractors shall ensure that Medivac procedures are incorporated into their
emergency response procedures as a part of their Loss Prevention Program (LPP).
28.9.2
The procedures to initiate a Medivac are covered in GI 1321.015.
Worker and Workmen Law

Saudi Labor and Workmen Law, Chapter 7 - Protection and Social Services, Labor
and Workmen Law, Articles 134-6.
Article 134
The employer shall provide first-aid services for the workmen in accordance with the
standards to be determined by the Minister of Labor in collaboration with the Minister of
Health. If the number of his workmen in a single location or town, or within a radius of
fifteen (15) kilometers, exceeds fifty (50), he shall employ a nurse who shall be familiar
with first aid services and shall be exclusively assigned to rendering such services; the
employer shall assign a physician to examine and treat the workmen at the place to be
provided by the employer for this purpose, and the employer shall provide them with the
medicines necessary for their treatment. The aforementioned services shall be free of
charge whether during work hours or otherwise. If in the cases mentioned above, the
number of workmen exceeds one hundred (100), the employer shall, in addition, provide
them with all other means of treatment in cases requiring treatment by specialists, or
performance of surgical other operations. In case operations are performed, as well as in
cases of incurable diseases, the expenses shall be taken from the Social Insurance Funds.
The costs of treatment, medicines and hospitalizations in government or charitable
hospitals, as well as the party, who will assume such costs, shall be determined pursuant
to the decision to be made by the Minister of Labor in agreement with the Minister of
Health, or to the rules laid down in the Social Insurance Law.

ATTACHMENT 2
Page 4 of 5
89
89
However, if the number of workmen is less than fifty (50), the employer shall provide the workmen with a
medical aid cabinet which shall be maintained in a good condition and shall contain the bandages,
medicines, and antiseptics to be determined by the Minister of Labor in agreement with the Minister of
Health, in order to provide workmen with first aid.
Article 135
Every employer who employs more than fifty (50) workmen shall inform the appropriate
Labor Office of the name of the physician who he has selected to treat his workmen. In
case he employs more than one hundred (100) workmen, he shall inform the Office of the
names of the physicians and specialists whom he has selected to treat his workmen, and
of the names of the hospitals which he has designated for that purpose. In both cases, he
shall notify the appropriate Labor Office of the minimum number of days fixed for the
examination of workmen, provided that this minimum shall not be less than three (3)
times a week.
Article 136
Every employer shall prepare for each workman a medical file showing the result of the
medical examination performed on the workman upon his employment, a description of
the cases of his illness, the stages of his treatment, and the periods of his absence from
work, provided that mention shall be made in the file of the kinds of ordinary and
occupational diseases and labor injuries.
ATTACHMENT 2
Page 5 of 5
90
90
Government Licensure of Professional Medical Personnel

Kingdom of Saudi Arabia Licensing Requirement Statement
Health profession practitioners must be licensed by the Ministry of Health (MOH)/Saudi Council for Health
Specialties (SCFHS) of the Kingdom of Saudi Arabia (KSA) to practice their profession in the Kingdom.
Purpose
To ensure that health profession practitioners:
1. Meet the licensure requirements of the MOH/SCFHS of the KSA prior to employment.
2. Are properly licensed by the MOH of the KSA to practice their profession in the Kingdom.
Definitions
1. Health Profession Practitioners A term used to describe Clinicians, Pharmacists, Nurses and
Technicians.
2. Government Licensure The issue of a license to practice the appropriate profession in the KSA, issued
by the MOH/SCFHS of license from the Ministry of Health.
Registration Objectives
1. Verify the practitioners competency.
2. Evaluate and classify practitioners certificates and experiences.
3. Introduce practitioners to the standards and ethics of practicing health professions in the Kingdom.
4. Monitor the practice of health professions to detect any incompetence or malpractice and deal with
them.
5. Emphasize that practitioners pursue continuing medical education programs to improve their skills and
keep up with the latest developments in their filed of specialty.
6. Protect the society from incompetent practitioners.
Registration Procedures
1. Fill out and sign each page of the SCFHS Application form for Accreditation and Professional
Registration.
2. Enclose originals of educational and experience certificates or authenticated copies.
3. Two (2) recent photos.
4. Sign the form of compliance with the standards with the standards and ethics of practicing health
professionals in Saudi Arabia.
SCFHS Contact Information
Telephone:
Web page:
e-mail:
Al-Khobar
(03) 896-6760
Riyadh
(01) 482-2415
www.scfhs.org.sa
scfhs@scfhs.org
Background History
In its session held on 14 Dhu al-Qadah 1416 (April 2, 1996), the Board of Trustees of the Saudi Council for
Health Specialties (SCFHS) approved the registration list of health profession practitioners. On 30 Muharram
1417 (June 16, 1996), it approved the regulations governing the registration of physicians and dentists. HE,
the Minister of Health and Chairman of SCFHS Board of Trustees, issued ministerial decision No. 1476/11,
dated 5 Rajab 1418 (November 5, 1997), stipulating the registration at SCHS in order to approve the practice
of health professions in both the public and private sectors in the Kingdom. This was circulated to all health
areas by letter No. 298/6093/20, dated 12 Rajab 1418 (November 12, 1997).
Government Licensure of Professional Medical Personnel
ATTACHMENT 3
Page 1 of 1
91
91
Scope of Service
Care Provided
Care includes triage, assessment, diagnosis, first aid, treatment, stabilization and transfer or Medivac to an
inpatient hospital for definitive care and response to disaster situations.
Treatment
Includes treatment of encounters of varying complexities, such as acute trauma, medical emergencies and
prescribing medicines.
Basic BLS and other first aid intervention. Use of AED, incorporating life saving measures with stabilization
techniques.
Investigations
Investigations include any tests/procedures that can be undertaken, e.g.:
1. Dip stick urine test.
2. Test strip blood test.
3. Hearing test.
4. Pulmonary function test (PFT).
5. 12 Lead EKG/Chest lead monitoring.
6. Pulse Oximeter and SPO2.
7. Visual Acuity (Snellen chart).
8. Employees Physicals.
9. Radiology.
10. Laboratory.
Patient Eligibility
Clear policy statement regarding who is eligible for care and what are they eligible for, e.g.:
a. For all employees.
b. For general public or non-employee with potentially serious or life threatening condition.
Scope of Service
ATTACHMENT 4
Page 1 of 1
92
92
Injury Summary
Medical Facility: ________________________________
Project No.: _____________________
Page: _________ of _________
Proponent:
File No.:
Date: _____________________
________________________________
Injury
No.
Name Injured
Badge Number
Craft
# of Injuries this month:
Report Prepared by:
_______________________________
Signature:
_______________________________
Title and Telephone:
_______________________________
_____________________
Date of
Accident
Carry
Over
Yes/No
Days Lost
this Month
Nature of Injury
and Body Part
Affected
Brief Description
of Accident. State
What, Where,
How and Why.
Total days lost
Injury Summary Report

ATTACHMENT 5
Page 1 of 1
93
93
Tetanus Vaccine Report
Medical Facility: ____________________________________

Date Given
Tetanus Vaccine Record
Patient Name
Company ID
Batch/Lot No.
Nurse Signature
ID No.
ATTACHMENT 6
Page 1 of 1
94
94
Cleaning of Blood Spills

Spills of blood can occur in your medical facility. So, it is essential to keep in mind that it is not possible to
identify patients with Hepatitis B virus (HBV) and/or Human Immunodeficiency Virus (HIV). Therefore, all
blood and blood borne pathogens shall be considered infectious.
A Blood Spill Kit shall be placed in all areas where blood spills are likely to occur, including medical facilities
in remote areas.
Each Spill Kit shall have the following items and supplies:
x
One two-compartment plastic pail (dual bucket).
Disposable shoe covers.
Disposable safety glasses or plastic goggles.
Disposable mask.
Disposable gloves.
Two (2) trigger sprayers or peri-bottle, labeled #1 and #2.
One (1) measuring glass.
Container of detergent/disinfectant mixed to correct ratio.
Container of 5.25% sodium hypochlorite (Clorox).
One (1) roll paper towel or disposable cleaning cloths (J-cloths).
One (1) roll color-coded plastic bags for disposable of infectious waste.
One WET FLOOR sign.
One (1) laminated copy of these instructions.
Cleaning Procedure:
1. Place WET FLOOR sign near to the spill.
2. Wear disposable gloves and mask.
3. If splashing is anticipated, protective eye wear, such as disposable goggles should be worn. Wear
disposable coverall/gown if soiling of clothes is likely.
4. If there is a chance that shoes could become contaminated, wear shoe covers.
5. Prepare the disinfectant/detergent solution according to the following prescribed ratio:
a.
One 1 ounce of Beaucoup solution per one (1) gallon of sweet water.
b. One 1 ounce of Clorox solution per nine (9) ounces of sweet water.
Note: For other chemical dilution ratios, see page 97.
6. Arrange the required color coded (yellow) bio-hazardous plastic waste bags, so they are ready to receive
contaminated waste.
7. Use disposable paper towels to soak up and remove all spilled blood or body fluid. Place soiled disposable
paper towels in the color coded (yellow) bio-hazardous bag. Repeat until all spilled blood or body fluid
has been removed.
8. Spray or apply adequate approved disinfectant solution (Beaucoup) on the spillage area. Clean the area
with fresh paper towels, being sure to remove all visible blood or body fluid. Dry with fresh paper towels.
Place soiled disposable paper towels in the color coded (yellow) bio-hazardous waste bag.
ATTACHMENT 7
Page 1 of 3
95
95
Spray or apply adequate Clorox solution on the spill area, ensuring that the entire spillage area is covered
with Clorox solution. Allow a two minute contact time and then wipe the area thoroughly with disposable
paper towels. Dry with fresh paper towels. Place soiled disposable paper towels in the color coded (yellow)
bio-hazardous bag.
9.
Wait for the area to completely dry before removing the WET FLOOR sign.
10.
Clean and disinfect the trigger spray bottles and other nondisposable items, as these items are
considered potentially contaminated.
11.
On completion of the task, place all disposable protective garments, such as gloves, shoe covers,
goggles and mask in the yellow plastic bag. Wash hands thoroughly using antiseptic soap, such as
Scrubstat.
12.
Replenish all disposable items in the spill kit and ensure it is ready for future use.
Spills/Splashing of Walls:
1.
Wear disposable gloves and mask.
2.
If splashing is anticipated, protective eye wear (goggles) should be worn. Wear gown if soiling of
clothes is likely.
3.
Wear shoe covers if there is a chance of shoes becoming contaminated.
4.
Prepare the disinfectant/detergent solution according to prescribed ratio.

a.
One 1 ounce of Beaucoup solution per one (1) gallon of sweet water.
b. One 1 ounce of Clorox solution per nine (9) ounces of sweet water.
5.
Arrange the required color coded (yellow) bio-hazardous plastic waste bags, so they are ready to
receive contaminated waste.
6.
Use disposable paper towels to soak up and remove all of the spilled blood or body fluid. Place
soiled disposable paper towels in the color coded (yellow) bio-hazardous waste bag.
7.
Spray or apply adequate SAMSO approved disinfectant solution (Beaucoup) on the spillage area.
Clean the area with fresh paper towels, being sure to remove all visible blood or body fluid. Dry
with fresh paper towels. Place soiled disposable paper towels in the color coded (yellow) biohazardous waste bag.
8.
Spray or apply adequate Clorox solution on the spill area, ensuring that the entire spillage area is
covered with Clorox solution. Allow a two minute contact time and then wipe the area
thoroughly with disposable paper towels. Dry with fresh paper towels. Place soiled disposable
paper towels in the color coded (yellow) bio-hazardous waste bag.
9.
If it is found absolutely necessary to use a yellow scouring pad, this scouring pad should then be
treated as infectious waste.
10.
Double bag the scouring pad in yellow color plastic bag for disposal.
11.
Clean and disinfect the trigger spray bottles and other nondisposable items, as these items are
considered to be potentially contaminated.
12.
On completion of the task, place all disposable protective garments, such as gloves, shoe covers,
goggles and mask in the yellow plastic bag. Wash hands thoroughly using antiseptic soap, such
as Scrubstat.
13.
Replenish all disposable items in the spill kit and ensure it is ready for future use.

ATTACHMENT 7
Page 2 of 3
96
96
Chemical Dilution Ratios
Beaucoup
Phenolic Germicidal Detergent
One (1) ounce (30 milliliter) of Beaucoup per 1 gallon (3.7 liters) of sweet water.
Floor Maintainer
Non-Ionic Surfactant Diethylene Glycol Mono Ethyl Ether
Three (3) ounce (30 milliliter) of Floor Maintainer per one (1) gallon (3.7 liters) of sweet water.
Six (6) ounce (60 milliliter) of Floor Maintainer per two (2) gallons (7.5 liters) of sweet water.
Upgrade
Quarternary Ammonium Germicidal Detergent
One (1) ounce (30 milliliter) of Upgrade per three (3) gallons (11.3 liters) of sweet water.
Biotek
Quarternary Ammonium Germicidal Detergent
One (1) ounce (30 milliliter) of Biotek per three (3) gallons (11.3 liters) of sweet water.
Deb
Qac Based Aromatic Disinfectant Cleaner
One (1) ounce (30 milliliter) of Deb per one (1) gallon (3.7 Liters) of sweet water.
Clorox
Liquid Bleach
One (1) ounce (30 milliliter) of Clorox per nine (9) ounces of sweet water.
Breaker
Alkaline Detergent
One (1) ounce (30 milliliter) of Breaker per three (3) gallons (11.3 liters) of sweet water.
Cleaning of Blood Spills - Chemical Dilution Ratios

ATTACHMENT 7
Page 3 of 3
97
97
Medical Equipment Minimum Requirements

The minimum quantity of medical equipment listed below is only a sample. The amount of equipment required to operate a Remote Area Clinic depends on the
clinics category and utilization rates.
Category A
Urgent Care
Facility
Minimum
Quantity
Category B
Urgent Care
Facility
Minimum
Quantity
Category C Urgent
Care Facility
Minimum
Quantity
Bag Mask Valve (BMV) with built-in CO2 detection

device (e.g., AMBU) adult, disposable.
Backboard, long with straps.
Description
Dressing cart, stainless steel.
Drug cupboard, lockable.
Automated External Defibrillator (AED), portable with

monitoring capabilities.
Emergency response bag.

See Attachment 15, page 120.
Exam/emergency stretcher with or without lockable

wheels, as applicable.
Bed observation.
NA
Entonox/nitronox unit, portable.
Examination light, wall mounted.
Refrigerator for staff, small, medium or large.
Refrigerator for chilled items/drugs, small, medium or

large.
Hare traction unit.
Infusion pump.
Intravenous (IV) stand, mobile. (Any device which

facilitates the hook up of IV bag/bottle is acceptable at
single room clinic).
Laryngeal mask (LMA), disposable sizes: 3, 4 and 5.
Ophthalmoscope/otoscope, desk top and/or wall

mounted.

ATTACHMENT 8
Page 1 of 2
98
98
Category A
Urgent Care
Facility
Minimum
Quantity
Category B
Urgent Care
Facility
Minimum
Quantity
Category C Urgent
Care Facility
Minimum
Quantity
Oxygen cylinders, D size, wall secured or cart.
Oxygen cylinders, E size, wall secured or cart.
Oxygen resuscitator unit (e.g., Robert Shaw or OxyViva resuscitator).
Portable emergency eye irrigation unit.
Pulse Oximeter (If not part of AED).
Ring cutter.
Scissors bandage.
Sharps contaminated disposable box.
Sphygmomanometer, aneroid type, desk top or wall

mounted.
Stethoscope.
Suction: Laerdal portable with rechargeable batteries.
Thermometer, electronic.
Visual acuity chart.
Stretcher: Scoop stretcher with straps.
Glucometer machine, calibration safe.
Pocket mask with oxygen nipple/inlet.
Wheel Chair.
Not applicable for single room facilities.
Weight/Height scale.
Stretcher emergency, disposable (e.g., Life lite

emergency), 5 per box.
Stretcher Basket.
At single room facility, to be part of operation
emergency response supplies.
Description

ATTACHMENT 8
Page 2 of 2
99
99
Medical Supplies Minimum Requirements

The minimum quantity of medical supplies listed below is only a sample. The amount of supplies required to safely operate a Remote Area Clinic depends on the
clinics category and utilization rates.
Item Description
Unit
Category A and B Facility
Category C Facility
Each
inch.
Each
1 inch.
Each
2 inch.
Each
Automated External Defibrillator (AED) electrodes and other

accessories.
Each
Alcohol preps.
Box
Aluminum foil, roll.
Roll
Ambu bag and mask with CO2 indicator, adult, disposable.
Each
Anal scope, disposable.
Each
Applicators, sterile, 6 inch.
Each
Applicators, non-sterile, 3 inch.
Each
Apron plastic.
Each
Bag: paper bag, preferable waxed.
Each
Band aids.
Box
Abdominal pads.
Quantity
Adhesive tapes, sizes:
Bandages: Stockinet bandages, sizes:

2 inch.
Roll
4 inch.
Roll
Bandages: Ace bandages, sizes:

2 inch.
Roll
3 inch.
Roll
4 inch.
Roll
6 inch.
Roll
Bandages: triangular bandages.
Each

ATTACHMENT 9
Page 1 of 8
100
100
Item Description
Unit
Category C Facility
Each
1.5 volts (D cell).
Each
1.5 volts (AA).
Each
1.5 volts (AAA).
Each
Battery: Chargeable battery for EKG machine, spare.
Each
Bandage scissor.
Each
Betadine swabs and/or solution sticks.
Each
Blood spill kit.

Each
Body bags.
Each
Burn dressing: Sterile burn sheet 60 x 90 cm.
Each
Burn pad 55 x 75 cm.
Each
Basin, kidney, disposable.
Quantity
Batteries, size:
Butterfly cannula, sizes:

19 gauge.
21 gauge.
23 gauge.
Catheter: Nasal catheter, sizes:
16 french.
EA
18 french.
EA
14 french.
EA
16 french.
EA
Catheterization set: urethral catheterization set, #14 french,

disposable.
EA
No neck adult.
Each
Small adult.
Each
Regular adult.
Each
Catheter: Suction catheter, sizes:
Cervical collars, hard, stiff neck brand only, sizes:

ATTACHMENT 9
Page 2 of 8
101
101
Item Description
Unit
Category C Facility
Cold packs.
Pack
Cotton balls, sterile, 10 packs.
Pack
Cardiopulmonary resuscitation (CPR) board.
Each
Glue, derma bond.
Each
Quantity
Drain: Penrose drain, sizes:

inch.
Each
1 inch.
Each
Dressing-release, non-adhering dressing.
Pack
Dressing pack, disposable.
Each
Dressing.
Each
Dressing: Tegaderm, 6 cm x 7 cm.
Each
Dressing: multi-trauma dressing, sterile.
Each
EAR speculum, dispenser.
Each
EAR speculum, box of 100.
Each
Electrocardiogram (ECG), recording paper.
Each
ECG adaptor clips/pads and/or suction bulbs.
Pack
ECG electrodes, disposable.
Pack
inch.
Each
1 inch.
Each
3 inch.
Each
Emergency blanket, aluminum polymer fire-retarded, body heat

retainer.
Each
Emergency blanket, 58 inch x 90 inch, disposable.
Each
Emergency eye wash solution, 16 ounce bottle.
Bottle
Eye pads, sterile.
Each
Filter, pocket mask.
Each
Flash light, heavy duty.
Pack
Forceps splinter, fine tip, disposable.
Each
Elastoplasts, sizes:

ATTACHMENT 9
Page 3 of 8
102
102
Item Description
Unit
Gauze: Roller gauze, non-sterile, sizes:
Roll
1 inch.
Roll
2 inch.
Roll
3 inch.
Roll
Category C Facility
4 inch.
Roll
Gauze: Sponge gauze, non-sterile, sizes:
Pack
2 x 2.
Pack
3 x 3.
Pack
4 x 4.
Pack
Gauze: Sponge gauze, sterile, sizes:
Pack
2 x 2.
Pack
3 x 3.
Pack
4 x 4.
Pack
Gloves: exam gloves, non-sterile, latex.
Box
Size 7.
Pair
Size 7.
Pair
Size 8.
Pair
Glucometer control solutions, as applicable.
Each
Goggles: safety goggles.
Each
Head immobilizer.
Each
Humidifier, disposable with adapter, Aquapak 500 ml.
Each
Quantity
Gloves: exam gloves, sterile, latex, sizes:
Intravenous (IV): Jelco IV catheter, sizes:

14 gauge.
Each
16 gauge.
Each
18 gauge.
Each
20 gauge.
Each
22 gauge.
Each

ATTACHMENT 9
Page 4 of 8
103
103
Item Description
Unit
Category C Facility
IV set, primary piggy back pump set for pump type.
Each
IV tubing, nitroglycerin set for IV pump.
Each
IV tubing, 15 drop set.
Each
Each
IV tubing, metriset.
Each
Kerlix rolls.
Each
Kleenex tissue.
Box
Lancets.
Box
3.
Each
4.
Each
5.
Each
Each
Mask face, disposable.
Box
Medicine cups.
Each
Quantity
Laryngeal mask airway (LMA), disposable, sizes:
Micropore tape, sizes:

inch.
Roll
1 inch.
Roll
2 inch.
Roll
Nebulizer sets.
Each
Needles, sizes:
18 gauge, 1-1 inch.
Each
20 gauge, 1 inch.
Each
22 gauge, 1- inch.
Each
Optivisor.
Each

ATTACHMENT 9
Page 5 of 8
104
104
Item Description
Unit
Category C Facility
Quantity
Oral airways, guedal, disposable, sizes:

Small.
Each
Medium.
Each
Large.
Each
Ophthalmoscope with accessories and consumables.
Pack
Oxygen connecting tubes.
Each
Oxygen flow meter, to fit various size cylinders.
Each
Oxygen masks adult, simple.
Each
Oxygen masks, non-breathing, adult.
Each
Oxygen nasal cannulas, adult.
Each
Paper cups.
Pack
Paper roll, vanco.
Roll
Paramedic scissor (sheer).
Each
Penlight (torch/flashlight).
Each
Percussion hammer.
Each
Pleur-evac chest drainage.
Each
Pocket masks with oxygen nipple.
Each
Probe cover for thermometer.
Box
Red dots (monitoring electrodes).
Pack
Safety pins, large.
Each
Safety goggles, disposable.
Each
Safety hard hat, size to fit.
Each
Scalpel handle, disposable with blades number 11 and 20.
Each
Shroud kit.
Each
Sharps box with wall brackets, large.
Each
Sharps box with large brackets, small.
Each
Sharps box, small ambulance.
Each
Shave prep kits.
Pack

ATTACHMENT 9
Page 6 of 8
105
105
Item Description
Spandages, sizes 1 to 7.
Unit
Category C Facility
Each
Splint: cardboard Sam splint:

Leg splint 24 inch.
Quantity
Each
Leg splint 18 inch.
Each
Leg splint 12 inch.
Bottle
Arm splint 18 inch.
Each
Arm splint 12 inch.
Each
Stretcher straps.
Each
Saline for irrigation, 1,000 cc, sterile.
Bottle
Box
1/8 inch.
Box
Suction machine with accessories and consumables.
Each
Box
Box
Mersilk 4/0 W329 NDL.
Box
Vicryl 5/0 W9106 NDL.
Box
Suture tray, disposable.
Each
Steri-strip, sizes:
inch.
Suture: Surgical suture, sizes:
Syringes with needles, disposable, sizes:

Each
Each
Each
Insulin, 50 unit/cc.
Syringes, disposable, sizes:

5 cc.
Each
10 cc.
Each
20 cc.
Each
50 cc.
Each

ATTACHMENT 9
Page 7 of 8
106
106
Item Description
Unit
Tape measure.
Each
Test strips for glucose in blood, 25s (Hemoglucotest).
Bottle
Test strips for glucose in urine, 25s (Ketodiabur-test).
Bottle
Thermometer: temperature gauge for refrigerator.
Each
Tongue blades, non-sterile.
Box
Towel sterile.
Each
Towel: Polyethylene, disposable.
Box
Urinals.
Each
Urinary drainage bag.
Each
Category C Facility
Quantity
Vaseline gauze, sizes:

inch x 72 inch.
Each
3 inch x 18 inch.
Each
Water: Sterile irrigation water, 2,000 cc.
Bottle
Wrench, adjustable metal type to open all cylinder sizes.
Each
Adhesive remover (e.g., Whisk).
Box
Yankauer suction.
Each
Multistix, urine test strips.
Bottle
ATTACHMENT 9
Page 8 of 8
107
107
Linen Supplies Minimum Requirements

The minimum quantity of linen supplies listed below is only a sample. The quantity of each item required to supply a Remote Area medical facility will vary
depending on the clinics category and utilization rate.
Note: Disposables, if available, are preferred.
Item Description
Unit
Bed sheets.
Each
Blankets.
Each
Pillows.
Each
Pillow cases.
Each
Plastic cover for pillows.
Each
Face cloths.
Each
Bath towels.
Each
Patient gowns.
Each
Linen hamper/container.
Each
Linen hamper bags.
Each
Quantity
Check ()
Linen Supplies Minimum Requirements

ATTACHMENT 10
Page 1 of 1
108
108
Drug Formulary List Minimum Requirement
Class
Minimum
Quantity
Required per
Class
Analgesic/Antipyretic Tablets
Generic and Presentation (Example)
Minimum
Stock Level
Remarks
Acetaminophen 500 milligram (mg) tablets

Acetaminophen with codeine
Acetylsalicylic acid 325 or 500 mg tablets
Analgesic/Anti-Inflammatory
Tablets
Diclofenac 50 mg tablets
2
Ibuprofen 400 mg tablets

Indomethacin 25 mg capsules
Naproxen 250 mg tablets
Analgesic/Anti-Inflammatory
Injection
Ketorolac tromethamine 15 mg/ml ampules
Amoxicillin 250 mg capsules

Augmentin 375 mg
Ciprofloxacin 250 mg
Antibiotic Tablets
Erythromycin 250mg
Doxycycline 100 mg
Azithromycin 250 mg tablets
Cefaclor 250 mg capsules
Penicillin VK 600 mg
Antibiotic Ointment
Bacitracin zinc 500 units/gram (gm)
Antibiotic Ointment for Burns
Bacitracin zinc ointment
Antacid Tablets
Antacid chewable tablets
Drug Formulary List Minimum Requirement

ATTACHMENT 11
Page 1 of 7
109
109
Minimum
Quantity
Required per
Class
Antacid Suspension
Maalox suspension
Adhesive Remover
Adhesive remover
Bronchodilator (Nebulizer)
Albuterol 20 ml solution/aerosol delivery

chamber
Class
Minimum
Stock Level
Remarks
Atrovent inhalation solution

Bronchodilator (inhaler)
Albuterol sulfate inhaler
Antiseptic Solution
Alcohol isopropyl 70% solution
Antiseptic Swab
Alcohol sachet
Algesal ointment, 40 mg tube
Analgesic, Cream and/or

Ointment
Stimulant
Ammonia 0.3 ml crushable ampules
Anesthetic Rectal
Cinchocaine 1% ointment, 20 mg tube
**Beta Blocker
Atenolol 50 mg tablets
Cough Medication, Syrup
Dextromethorphan 100 ml bottle
Diclofenac cream/ointment
Ibuprofen cream/ointment
**Not for Category C Facility
Diphenhydramine hydrochloride
Rinofed
Drug Formulary List - Minimum Requirement

ATTACHMENT 11
Page 2 of 7
110
110
Class
Minimum
Quantity
Required per
Class
Minimum
Stock Level
Remarks
Betamethasone valerate 0.1% cream, 30

gm tube
Corticosteroid Cream
Laxative Tablets
Bisacodyl 5 mg tablets
Antipruritic
Calamine lotion
Otic Drops, Cleanser
Carbamide peroxide 6.5%
Kenacomb
(nystatin/gramicidin/triamcinolone) cream
Cetirizine 10 mg tablets
Diphenhydramine 25 mg capsules
Antihistamine Tablets/Capsules
Antihistamine Injection
Diphenhydramine 50 mg/m injection
Antiseptic Cleanser/Scrub
Chlorhexidine gluconate 4% scrub,

500 ml
Ophthalmic Drops, Antibiotic
Promethazine hydrochloride (HCL)

25 mg tablets
Chloramphenicol 0.5%, 10 ml dispenser

Erythromycin ointment
Tears naturale solution, 15 ml dropper
**Ophthalmic Drops, Myotic
Ophthalmic, Antihistamine
Pilocarpine HCL 2% ophthalmic solution,

15 ml dropper
Cromolyn sodium 2%, 10 ml bottle

Prefrin-A, 15 ml dropper

ATTACHMENT 11
Page 3 of 7
111
111
Minimum
Quantity
Required per
Class
Ophthalmic Drops, Anesthetic
Oxybuprocaine HCL, 0.4% solution,

10 ml dropper
Ophthalmic Drops, Diagnostic

Agent
Fluorescein sodium, single use applicator
Ophthalmic, Irrigation/Dry
Eye/Eyewash
Sodium chloride, 0.9% eye drops, 15 ml

dispenser
Class
Minimum
Stock Level
Remarks
Clotrimazole 1% cream, 20 gm tube

Clotrimazole 1% solution, 20 ml bottle
Antifungal
Daktacort cream, 2% miconazole,

1% hydrocortisone, 15 ml tube
Miconazole nitrate 2% powder, 20 gm
Cromolyn sodium 2% solution, 30 ml spray
Nasal Drops, Antihistamine
Nasal Drops, Anti-Infective

Steroidal Anti-Inflammatory
Otosporin otic drops, polymyxin, neomycin,

hydrocortisone, 5 ml bottle
Nasal Decongestant
Pseudoephedrine HCL - 120 mg sustained

release tab
**Gastric - H2 Blocker
Oxymetazoline HCL - 0.05% solution, 10

ml dropper
**Famotidine 40 mg tablets
**Ranitidine 150 mg tablets
ATTACHMENT 11
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112
112
Minimum
Quantity
Required per
Class
**Gastric - H2 Blocker Injection
Ranitidine 25mg/mL, 2 ml for IV or

intramuscular (IM) use
Antiemetic Tablets
Metoclopramide HCL - 10 mg tablets
Antiemetics Injection
Metoclopramide HCL - 5 mg/ml injection
**Diuretic Tablets
Furosemide 40 mg tablets
Diuretic Injection
Furosemide 10 mg/ml vial, 2 ml
Diuretic Infusion
Mannitol 20% solution, 500 ml bag

for IV
Antispasmodic Tablets
Hyoscine N-butylbromide 10 mg tablets
Antispasmodic Injection
Hyoscine-N-butylbromide 20 mg/ml,
1 ml Ampule for IM, IV or SC use
Antidiabetic - Miscellaneous 1
Glucose powder
Antidiabetic - Miscellaneous 2
Glucose 50% IV solution, 50 ml prefilled

syringe
Antidiabetic Hyperglycemic
Agent, Injection
Glucagon 1 mg (1U) with 1.5 ml solvent
Antidiabetic Hyperglycemic
Agent, Injection
**Insulin human isophane 100 U/ml

isophane suspension, 10 ml vial
Class
Minimum
Stock Level
Remarks
Insulin regular 100 U/ml 10 ml vial


ATTACHMENT 11
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113
Minimum
Quantity
Required per
Class
**Glucophage 500 mg tablets
Miscellaneous 1
Silver nitrate applicators
Miscellaneous 2
Throat lozenges
Miscellaneous 3
Glycerin 4 ounce bottle
Anti-Diarrhea
Loperamide HCL 2 mg capsules
Class
Antidiabetic Hypoglycemic
Agent, Tablets
Minimum
Stock Level
Remarks
Lidocaine HCL 1% solution, 20 ml

multi-dose vial
Anesthetic, Local Injection
Anesthetic Local, Other
**Beclomethasone
Disproportionate, Bronchodilator
Oral inhaler, 50 microgram (mcg) per

inhalation
IV Fluids, Dextrose
Dextrose 5% bottle/bag, 1 liter
IV Fluids, Lactated Ringers (LR)
Lactated ringers solution 1,000 ml
IV Fluids, Sodium Chloride (Na)
Sodium chloride 0.9% 1,000 ml
Emollient (Lubricant)
KY Jelly 5 mg tube/petrolatum white
**Antiparasitic
Mebendazole 100 mg chewable tablets
Muscle Relaxant
Methocarbamol 500 mg tablets
Lidocaine HCL 2% solution, 20 ml

multi-dose vial
Lidocaine 2% Jelly - 20 gm tube
Oral viscous 2%, 122 ml bottle

ATTACHMENT 11
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114
Class
Minimum
Quantity
Required per
Class
Minimum
Stock Level
Remarks
Sodium chloride 10 or 20 ml ampule
Diluent
Rehydration Agent
Oral rehydration salts 14 gm sachet
Tetanus Vaccine Immunoglobulin
Tetanus immune globulin 250 IU per ml 1

ml vial/syringe for intra muscular (IM) use
Tetanus Toxoid
Tetanus Toxoid 0.5 ml dose for IM
Urinary Anesthetic
Phenazopyridine HCL 100 mg tablets
Cleanser (Anti-Infective)
Povidone iodine 10% solution, 120 ml

bottle
Steroid Anti-Inflammatory Tablet
Water for injection 10 ml ampule
Prednisone 5 mg tablets
Steroid Anti-Inflammatory
Injection
Hydrocortisone injection 100 mg for IV or

IM
**Anticonvulsant Agent,
Noncontrolled
Fosphenytoin sodium 50 mg/ml 10 ml

ampule for IV or IM
**Anticoagulant
5,000 units/ml vial
Vasodilator (Nitrate)
Isosorbide dinitrate 10 mg tablets
**Not to be supplied to Category C Medical Facility.

Note 1:
Generic and Presentation - Supply of generic alternatives from the local market is acceptable.
Note 2:
Formulary list/crash cart and other emergency drugs supplies:

Formulary list (a selection from each class of drug for category A, B and C Medical Facility) and crash cart contents is at the discretion of the company assigned
responsible physician who must comply with all Ministry of Health (MOH) drugs supply and administration regulations, and take into consideration the competency of
the staff and required training before such drugs are administered.

ATTACHMENT 11
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115
Ambulance Medical Equipment and Supplies Minimum Requirement

Description
1.
2.
3.
Quantity
Week 1
Week 2
Week 3
Week 4
External:
a.
Red Crescent insignia.
b.
Ambulance sign painted on the outside.
Drivers Cabin:
a.
Gloves, heavy duty.
b.
Note pad and pen.
c.
Fire extinguisher, ABC type - small.
d.
Safety hard hat.
e.
Flashlight, 9 volt.
f.
Tire gauge.
g.
Safety triangle.
h.
Communication equipment (radio).
i.
Safety vest, reflective with identity clearly labeled (e.g., medical).
Patient Compartment:
a.
First aid kit (36 unit size) with the following items: ace
bandages, kerlix, cold packs and scissors.
b.
**Emergency response bag.
c.
**Automated External Defibrillator (AED).
d.
**Suction machine, portable with accessories, suction catheters

and tubing.**
e.
Stretcher collapsible (Ferno or other).
f.
Backboard short with straps.
g.
Long Board with straps, van type only.
h.
Kendrick extrication device (KED).
ATTACHMENT 12
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116
Description
3.
Quantity
Week 1
Week 2
Week 3
Week 4
Patient Compartment: (Cont.)

i.
Hare traction.
j.
Oxygen cylinder, large size, modular and van type only.
k.
Portable oxygen (e.g., Robert Shaw unit).
l.
Oxygen supplies accessories: rebreathing mask, nasal cannula

and tubing.
m. Oxygen cylinder key.

n.
Wrench adjustable, metal type to open all cylinder sizes.
o.
Infection control supplies:
Goggles.
Mask, surgical.
Plastic apron.
Gloves, examination.
Small sharps container.
Infectious wastes plastic bag, yellow.
p.
Cervical collar, rigid, size: small, medium and large.
q.
Other items:
Kleenex tissue.
Trash bag, plastic.
Gloves examination, unsterile.
**To be loaded upon dispatch of ambulance.

ATTACHMENT 12
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117
Vehicle (Ambulance) Condition Report Daily Checks

Medical Facility: ____________________
Vehicle No.: ____________________
Item Code
A.1
A.2
A.3
A.4
A.5
A.6
A.7
A.8
A.9
A.10
A.11
A.12
A.13
A.14
A.15
A.16
A.17
A.18
A.19
A.20
A.21
A.22
A.23
A.24
A.25
A.26
Day Checked and Initials
Items Checked
Remarks if Deficient
General cleaning inside and outside.

Air conditioning.
Directional lights.
Fuel gauge.
Horn.
Siren.
Mirrors.
Steering wheel.
Seat belts.
Hand brake.
Foot brake.
Radio communication.
Engine oil/Transmission oil.
Fan belts.
Radiator.
Wiper water reservoir level.
Battery.
Flashers.
Head lights, low and high beam.
Tail lights.
Stop lights and parking lights.
Muffler.
Tire condition and pressure.
Spare tire and tire changing tools.
Triangle.
Fire extinguisher.
Daily Test Run Mileage Record (km)
Mileage - Out
Mileage - In
Vehicle (Ambulance) Condition Report Daily Checks
ATTACHMENT 13
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118
Housekeeping Equipment and Supplies Minimum Requirement

The quantity of each listed below depends on the medical facility category and utilization rate.
Description
Check ()
Remarks
Mops, two (2) different colors.

Trolley with dual mop bucket and wringer/portable bucket with wringer for small clinic.
J cloth.
Sodium hypochlorite (Clorox bleach).
Antiseptic scrub for sinks (hibiscrub/hro-scrub 4).
Trigger spray bottle.
Detergent, upgrade or similar, e.g., beaucoup for patient area.
Plastic bags for rubbish, color coded for infectious waste.
Paper towels for sinks and spills.
Paper towel dispenser.
Wet Floor sign.
Blood Spill Kit.
Floor polish.
Window cleaner.
Furniture polish.
General multi-cleaner with bleach for sinks, etc.
Toilet bowl and urinal cleaner.
Soap, liquid and dispenser.
Waste bin, pedal type with lid for clinical waste.
Waste basket, general purpose.
Hand brush and dust pan.
Gloves rubber, heavy duty.
Hand sanitizer, ethyl alcohol 70% base, Sani-gel or Septogel.
Housekeeping Equipment and Supplies Minimum Requirement

ATTACHMENT 14
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119
Emergency Response Bag Minimum Requirement

At a minimum, each bag shall contain the supplies listed below. The contents of the emergency response bag shall be checked weekly or preferably after use to
ensure quantity and validity.
Note:
x
The QUANTITY for each item varies from one facility to another.
At a minimum, the NUMBER of emergency response bag per facility, as follows: two (2) bags in Physician Operated Clinic (POC) and one (1) bag in Nurse
Operated Clinic (NOC).
Emergency response bag is used when responding to medical emergencies and disasters, and in the medical facility.
Item
Nurse Supplies
IV Supplies
Contents
Quantity
Sphygmomanometer and stethoscope.
One (1)
Paramedic scissors (shears).
One (1)
Penlight.
One (1)
Disposable gloves, medium and large.
Three (3) each
Masks.
Three (3)
Waxed paper bag.
Three (3)
Small sharps container for sharps.
One (1)
Lactated ringers (LR), 1,000 cc.
One (1)
Dextrose 5% solution, 1,000 cc.
One (1)
Normal saline (9NS), 1,000 cc.
One (1)
Adhesive tape, 1 inch.
One (1)
Giving set.
Two (2)
Alcohol swabs.
IV Cannula:
Check ()
Six (6)
14 gauge to 20 gauge.
22 gauge.
Two (2) each

Two (2)
Band aids.
Six (6)
Tourniquets, 1 inch or inch.
One (1)
Tegaderm, 6 cm x 7cm.
Three (3)
2 x 2 gauze sponge.
Four (4)

ATTACHMENT 15
Page 1 of 2
120
120
Item
Contents
Ambu bag, adult.
One (1) each
Laryngeal mask, sizes: small, medium and large.
One (1) each
Syringe, 10 cc.
Pocket mask, adult.
Oxygen masks/nasal cannula/non-rebreather.
One (1)
Suction catheters, size 14 french.
One (1)
Multi-trauma dressing.
One (1)
Triangular bandage.
Kerlix roll.
Ace wraps, 4 inch x 6 inch.
One (1)
Six (6) each
Six (6)
Two (2)
Two (2)
Two (2) each
Non-adhesive dressing.
One (1)
Micropore, 1 inch.
One (1)
Povidine iodine swabs.
Four (4)
Ice pack.
Two (2)
Band aids.
Patient Supplies - Burn Supplies
One (1)
One (1) each
One (1)
Vaseline gauze, 3 inch x 18 inch.
Patient Supplies - Splints
Four (4)
Yankauer suction.
Gauze sponges, sterile, 2 x 2 and 4 x 4.
Patient Supplies - Dressings / Bandages
One (1) roll
Suction connecting tubing.
Abdominal pad.
Splints, disposable, short and long.
Check ()
One (1)
Oral airway, sizes: small, medium and large (3, 4 and 5).
Bandage, 1 Inch.
Patient Supplies - Airway Supplies
Quantity
One (1) tube

Six (6)
One (1) each
Sterile sheets, disposable.
Five (5)
Blankets emergency, disposable.
Two (2)
Surgical face masks, disposable.
Five (5)
Sterile gloves, sizes: 6.5, 7 and 8.
Two (2) pairs each
Disposable gowns.
Two (2)
Sterile sheets, disposable.
Five (5)

ATTACHMENT 15
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121
Emergency Drugs for Emergency Response Bag Minimum Requirement

At a minimum, facilities in each category shall have the drugs listed below for each bag. The contents of the emergency response bags shall be checked weekly or
preferably after use to ensure quantity and validity.
Note:
x
x
Staff must be certified competent to administer these drugs.

Other drugs can be added to this list provided that the staff is appropriately trained and certified competent to administer them.
Quantity
Item
Emergency Drugs
Drug Name and Strength
Adenosine 6 mg/2 ml ampule.

Amiodarone Injection, 150 mg/3 ml ampule.
Atropine sulphate 1 mg/10 ml, pre-filled syringe.
Albuterol inhaler, 200 inhalations, inhaler.
Calcium Chloride 10%, 1gm/10 ml, pre-filled syringe.
Diphenhydramine 50 mg/1 ml vial.
Dopamine infusion, 200 mg/5 ml vial.
Dextrose 50% injection, 50 ml pre-filled syringe.
Epinephrine 1: 1,000, 1 mg/1 ml.
Epinephrine 1: 10,000, 1 mg/10 ml pre-filled syringe.
Glucose powder, oral, bottle.
Glucagon injection.
Hydrocortisone injection, 100 mg/2 ml vial.
Inderal (propanolol) ampule.
Magnesium sulphate injection, 1 gm/2 ml ampule.
Nitroglycerin tablets, 0.4 mg bottle.
Nitroglycerin 50 mg vial.
Normal saline, 10 ml ampule.
Sodium bicarbonate, 50 mEq/50 ml pre-filled syringe.
Vasopressin injection, 20 units/ml vial.
Xylocard 2% (20 mg/ml), abboject.
Xylocard 20% (200 mg/ml), abboject.
Xylocaine spray 10%.
Physician
Operated Facility
Category A & B
Nurse Operated
Facility
Category C
Five (5)
Three (3)
Three (3)
One (1)
Two (2)
One (1)
Four (4)
One (1)
Six (6)
Six (6)
One (1)
Two (2)
One (1)
Three (3)
Four (4)
One (1)
Two (2)
Five (5)
One (1)
Two (2)
Two (2)
Two (2)
One (1)
Not applicable
Not applicable
Not applicable
One (1)
Not applicable
One (1)
Not applicable
Not applicable
Six (6)
Not applicable
One (1)
Two (2)
Not applicable
Not applicable
Not applicable
One (1)
Not applicable
Five (5)
Not applicable
Not applicable
Two (2)
Not applicable
Not applicable
Check ()
Emergency Drugs for Emergency Response Bag Minimum Requirement

ATTACHMENT 16
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122
Patient Treatment Daily Log

Medical Facility: _______________________________________________________
Date
Name and Badge No.
Time In
Time Out
Date: _______________________________
Treatment
Comments
Report prepared by:

Name: _____________________________________
Badge No.: ________________
Signature: _______________
Date: _____________
Patient Treatment Daily Log

ATTACHMENT 17
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123
Examination and Treatment Protocol (TP) for Nurses

TP-xx
Backache
Body Parts Involved:
Vertebrae, Spine ______________________________________________
Name: ___________________________
Badge No.: ________________
Date: _____________________
Time in: ________________
MR No.: ____________
History and Physical Examination

1.
Is onset of pain sudden

Is pain referred
Recent heavy lifting
History of spondylosis
History of rheumatoid
History of arthritis
2.
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
History trauma
History of renal calculus
Movement restriction
History of disc prolapsed
Yes
Yes
Yes
Yes
No
No
No
No
3.
Is pain Mechanical: Made worse by prolonged sitting or standing, relieved by movement or inflammatory agent or
prolonged early morning stiffness and is relieved by exercise _____________________________________
Are there any sensory or motor symptoms?
Yes
No
If yes, describe: _________________
4.
Any change in bowel or bladder function?
5.
6.
Vital Signs:
Urinalysis:
Yes
Temperature: _________
Yes
No
If yes, list: _____________________
No
BP: _________
Pulse: _________
Respiration: ________
If yes, list result: _____________________________________
Guidelines for Treating Nurse

1.
2.
Prior history of long standing backache and normally on prescribed medication, this should be given to the patient if
available (with no other presenting symptoms) otherwise:
In all cases of persistent backache the patient should be seen or referred to a clinician with the following
instructions:
x
Used of proper body mechanics when moving or lifting heavy objects.
Bend at the knees and hips when lifting and use the feet to pivot. Keeping the spine perfectly straight, do not
bend or twist the back.
Keep loads close to the body when lifting.
Avoid aggressive exercises when in pain.
Note: Give patient education guidelines for safe lifting techniques.
If back pain is work-related, prepare and submit QI-30.

x
History of work-related injury to company employee or contractor.
History of injury to general public resulting directly from company operations or on company premises.
Examination and Treatment Protocol for Nurses

ATTACHMENT 18
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124

TP-xx
Headache
Body Parts Involved:
Neurological System ______________________________________________
Name: ___________________________
Badge No.: ________________
Date: _____________________
Time in: ________________
MR No.: ____________
History and Physical Examination

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
History of recurrent headache

Trauma recent (within 24 hours)
High velocity
Sudden onset
Fully alert and orientated
Pyrexia
General Malaise
Nausea and vomiting
Sinusitis
Earache
Hypertension
Epilepsy
Psychiatric illness
History of alcohol abuse
Severe pain
Trigeminal neuralgia
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Migraine
Within last 7 days
Blunt injury
Loss of consciousness
Photophobia
Neck Rigidity
Drowsiness
Impaired vision
Flu like symptoms
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Hypotension
Yes
No
Stress
Drug or solvent abuse
Localized pain
Yes
Yes
Yes
No
No
No
Guidelines for Treating Nurse

In the event of sudden onset of severe headache with or without neurological symptoms, the patient
must be seen by a clinician as soon as possible.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Where history of head trauma, baseline observations, such as: temperature, pulse, blood pressure, respirations, and
pulse oximeter must be performed and recorded.
If there is any loss of consciousness or disturbance of conscious level, ensure that the patients airway is protected at
all times.
A Glasgow coma scale and neurological status must be obtained and recorded.
If a patient presents with neck rigidity, photophobia, nausea, vomiting, and/or dizziness, he must be seen by a
clinician and referred to hospital as soon as possible.
If a patient presents with hypotension or hypertension, with no prior history, he must be seen by a clinician as soon
as possible.
Patients with prior history of migraine or longstanding headache, normally on prescribed medication; the patient
shall be asked when medications were last consumed/taken.
A patient presenting with associated common cold or influenza, treat as instructed by the clinician.
Prolonged history of recurrent headache, with no prior investigations should always be referred to a clinician for
evaluation.
If a patient presents with any neurological disturbance he shall immediately be examined by a clinician.
ATTACHMENT 18
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125
Standing Orders Guidelines for Nurses

In the event nurses are authorized to administer and dispense drugs in the absence of a physician or pharmacist, clear
written administration and dispensing guidelines in line with MOH regulations must be in place. This could be in the form
of a standing order or a routine order from the responsible physician.
Note: The guidelines listed below are to be used as a reference to assist you in developing your own standing
orders/protocols.
Standing Orders (SO)

Treatment/Education
Refer to facilitys Nursing Protocol.
Always take patients blood pressure.
Headache
Headache of recent onset with normal vital signs and no

other complaints, give panadol per schedule dosage.
Headache associated with sore throat or common cold,
give panadol per schedule dosage.
Headache with dizziness, give panadol per schedule
dosage and 1 tablet of dramamine three times a day (tid).
Refer to Physician
Refer if headache is associated
with any of the following: high
blood pressure, high fever,
nausea, vomiting, history of
injury and acute severe
headache.
Refer if persistent headache.
Refer if history of head trauma.
Dramamine requires a physicians
order.
Follow facilitys Nursing Protocol if chest pain is not

associated with the typical symptoms of heartburn and/or
indigestion.
Notify the physician.
Start IV to keep vein open.
Give Morphine sulfate per physicians order.
Chest Pain
ALWAYS REFER ALL CASES
Place patient in semi-fowlers position.

Start oxygen 6 liters per minute.
Place on Life Pak monitor, if available.
Twelve lead EKG, if available.
IV fluids and morphine require a

physicians order.
Take vital signs as often as necessary and document.

Transport by the quickest method to the nearest medical
facility.
Accompany patient during transportation.
Apply analgesic balm.
Backache
Common Cold
Mild or recent onset without any associated complaints,

give panadol per schedule dosage. If no improvement in
two days, refer to physician.
Mild cold without any associated complaints (i.e., fever,

productive cough, etc.), give panadol per schedule
dosage.
Refer all other cases.
Common cold associated with

any of the following:
Temperature over 38 Celsius
(104.4 Fahrenheit), loose
productive cough with purulent
sputum, earache, sinus pain or
rhinorrhea.

ATTACHMENT 19
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126

Treatment/Education
Refer to Physician
Give isopto cetamide eye drops every 4 hours.

Conjunctivitis (mild)
Check G6PD status.
Refer severe cases.
Give erythromycin eye ointment to be applied at bedtime.
Erythromycin and isopto

cetamide require a physicians
order.
Refer all cases.
Analgesics require a physicians
order.
If no improvement in 48 hours, refer to physician.

Flash Burn of Eye
Patch the affected eye with an eye pad.

If indicated, apply analgesic.
Check vision on eye chart and record prior to eye
examination.
Foreign Body in Eye
If simple foreign body, apply novesine 0.4%, 2 drops;

remove foreign body with sterile cotton bud.
Refer all cases Stat.
Use normal saline as eyewash after removal.
Novesine requires a physicians

order.
Other foreign objects: perform first aid treatment only,

apply novesine 0.4%, 2 drops, cover eye with eye patch.
Reevaluate in two hours.
Itching Sensation in
Eyes
If no evidence of acute irritation, recommend cold

compress 3 times a day.
Give prefrin-A 1-2 drops, every 6 hours.
Advise patient to return If no improvement in 48 hours,
refer to physician.
Prefrin-A requires a physicians

order.
Apply warm, moist compressed for 15 minutes four times

a day (qid).
Sties
Give isopto cetamide eye drops every four hours and

Erythromycin eye ointment at bedtime.
Check G6PD status.
Advise patient to return if condition worsens or persists
longer than 3 days.
Give first aid treatment.
Trauma to Eyes
Cover both eyes with normal saline pads.

Immobilize impaled object.
Refer all cases.
Check tetanus status.

Foreign Body in Ear
If foreign body (such as fly) appears easy to remove,

irrigate with warm normal saline solution using bulb
syringe.
Other Eye Complaints
Refer if foreign body appears

impacted (such as a bean or small
stone) or is difficult to remove by
irrigation.
Refer all cases.
Apply otosporin ear drops every (q) 6 hours.

Ear Discharge, Ear
Pain
Never plug ears with cotton.

Give panadol per schedule dosage for pain.
Refer all cases.
Give Auralgan ear drops for earache.

ATTACHMENT 19
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127

Treatment/Education
Refer to Physician
Impacted Cerumen
Irrigate with warm saline solution only if patient has no

history of perforation of tympanic membrane or otitis
media.
If unable to remove, use murine ear drops (carbamide
peroxide), 5-10 drops twice a day (bid).
Examine ears for underlying infection.
Refer all cases.
Allergic Rhinitis
If this is the first instance of allergy, give antihistamine

and refer to a physician.
Refer if not previously diagnosed.

Refer if no improvement after
taking medication.
Epistaxis (minor)
Examine nasal passages.

Keep patients head erect, pinch side of nose against
septum for five (5) minutes.
May apply vaseline gauze nasal packing if necessary.
Check and record blood pressure and pulse prior to
physician referral.
Mild Throat Irritation

with Normal
Temperature
Recommend warm saline gargles or mouth spray.
Mild Sore Throat with

Temperature of 38 C
Tonsillitis with
Temperature of 38 C
Cough Associated
with Common Cold
Heartburn/
Indigestion
Vomiting
Abdominal Pain
Diarrhea
Give panadol per schedule dosage.

Give romilar expectorant, 2 teaspoon (tsp) every 4-6
hours, as needed.
See nursing protocol for upper respiratory infection.
Give liquid Maalox (antacid) 2 teaspoon every 4 hours or
Maalox tablets, 2 tablets every 4 hours.
Provide dietary advice: reduce spices, fried foods, etc.
Refer all cases.

Refer if persistent or recurrent
cough.
Refer if cough is associated with
any of the following: weight loss,
elevated temperature, purulent
sputum or hemoptysis.
Refer recurrent cases.
Refer if chest pain remains a
possibility.
Nothing by mouth (NPO) till evaluated.

Monitor vital signs.
Give anti-emetic for severe cases.
Close observation.
Refer all cases.
Refer in sickle cell disease and if

severe cases associated with any
of the following: nausea,
vomiting, fever, tenderness and
abdominal guarding.
Refer severe diarrhea.
Give imodium (Loperamide HCL), 2 capsules (4 mg)

initially, then 1 capsule every bowel movement (qbm);
maximum of 8 capsules (16 mg) in 24 hours.
Refer all severe cases associated

with any of the following:
nausea, vomiting, fever, blood in
stool and dehydration.

ATTACHMENT 19
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128
128

Treatment/Education
Constipation
Hemorrhoids
Rectal Bleeding
Burning and
Frequency of
Urination
Urethral Discharge
Give milk of magnesia 2 tablespoons (tbsp) (2 oz) or

dulcolax 1-2 tablets at bed time.
Advise patient to increase fluid intake, fruit and
vegetables in diet and moderate exercise.
Give anusol suppository and advise sitz baths, 20-25
minutes daily. Repeat process every day until relief is
obtained.
Joint Pains
Dry Skin
Dry Lips
Heat Rash
Boils
Corns
Lice (Head)
Refer all cases.
Refer to facilitys Nursing Protocol on Urinary Tract

Infection.
Refer all cases.
Refer to facilitys Nursing Protocol on Urinary Tract

Infection.
Refer all cases.

Refer all cases.
Refer all cases.
Refer all cases.
Apply analgesic balm and give panadol per schedule

dosage.
If associated with common cold or sore throat, treat as
common cold or sore throat.
Localized with no redness or swelling, give panadol per
schedule dosage and analgesic balm for local application.
Advice hot compresses or sitting in hot bath.
If associated with common cold or sore throat, treat as
common cold or sore throat.
Apply vaseline ointment.
Give lanolin, ounce (oz).
Give vaseline ointment.
Apply calamine lotion locally.
Advise patient to keep skin dry, bathe only once a day,
avoid bathing in hot water, wear lightweight clothing.
Advise warm water or saline compresses.
Give bacitracin ointment four times a day (qid) if lesion
not ready for incision and discharge (I&D).
Give panadol to relieve pain per schedule dosage.
Change dressing daily.
Athletes Foot
Refer constipation associated

with abdominal pain, nausea
and/or vomiting.
Refer all cases.
Pain Suggestive of
Renal colic
Gross Hematuria
Acute Scrotal
Swelling and Pain
Generalized
Musculoskeletal Ache
or Pain
Refer to Physician
In chronic phase with scaling, give daktarin powder or

canesten cream and advise good hygiene.
For removal of corns apply 1 drop of collomack solution
in the morning and evening. After a few days of
treatment, soak foot in hot bath to loosen the corn for
removal.
Apply 1 ounce of kwell shampoo and rub vigorously for 4
minutes, then wet hair with warm water and rinse
thoroughly. Repeat treatment in one week.
Refer if more than two days

duration.
Refer if temperature is elevated
over 38 C.
Refer if associated with any of
the following: redness, swelling,
elevated temperature.
Refer if condition worsens or
persists.
Refer if boil is on nose or upper

lip.
Refer if signs of cellulitis.
Refer if multiple boils, recurrent
or with abscess formation.
Refer if acute with maceration or
infected.
Medication requires physicians
order.
Refer if diabetes or infection.
Kwell shampoo requires a

physicians order.

ATTACHMENT 19
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129

Treatment/Education
Refer to Physician
Give Kwell cream or lotion.

Apply a thin layer to hairy infected areas and adjacent
areas.
Lice (Body)
Leave on overnight (8-12 hours) then wash off.

Repeat application in one week.
Kwell shampoo requires a

physicians order.
Discuss hygiene/contagion.
Family members may need treatment.
Herpes Simplex
Apply povidone-iodine 10% (clonidine) or 70% alcohol to

the affected area.
Requires a physicians order.
Report all on/off-the-job injuries as per your organization

guidelines.
Injuries
Evaluate need for tetanus immunization and immunize as

indicated.
Refer all cases.
Initiate immediate first aid treatment for all injuries.

Elevate affected part.
Contusion(s)
Apply cold compresses to diminish edema.
Refer if contusion(s) severe.
Apply ace bandage as appropriate.

Elevate and rest affected part.
Apply cold compresses or ice bag for first 12 to 36 hours.
Sprains
Give panadol for pain per schedule dosage.

Apply ace bandage.
Refer if severe, gross swelling,

fracture and/or loss of function.
Apply heat after 36 hours.

Cleanse with soap and water or saline.
Abrasions and
Superficial Punctures
Irrigate thoroughly.
May apply antiseptic ointment or vaseline dressing.
Evaluate need for tetanus toxoid immunization and
immunize as indicated.
If minor, such as nail wound:
Clean and apply dry, sterile dressing.
Lacerations (if Minor)

Advise patient to return if pain persists or signs of
infection appear.
Refer if all other lacerations.

Refer if patient returns with
persistent pain or signs of
infection.

ATTACHMENT 19
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130

Treatment/Education
Refer to Physician
Refer to minor burn treatment protocol.

Wash affected area gently with detergent soap
(povidone-iodine detergent is recommended).
Rinse thoroughly.
Minor Burns (first
degree or small
second degree burns)
Do not apply ice. Ice has the theoretical disadvantage of

vasoconstriction and possible ischemia of tissue in and
adjacent to the burn.
Apply bacitracin dressing and change every 48 hours.
Refer if more extensive or severe

burns.
Refer if burns involving face,
hands, soles of feet or perineum.
Refer if all circumferential burns.
Refer if any signs of sepsis.

Refer to burns treatment protocol.
Remove clothing.
Flush vigorously with several liters of water; shower if
possible.
Chemical Burns
(except of eyes)
Do not waste time looking for s specific neutralizing

agent.
Treat as thermal burns.
Monitor breathing closely for signs of pharyngeal swelling
and airway occlusion.
Refer if more extensive or severe

burns.
Refer if burns involving face,
hands, soles of feet or perineum.
Refer if all circumferential burns.
Refer if any signs of sepsis.
Obtain name of chemical and MSDS instructions.

ATTACHMENT 19
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131
Staff Competency Assessment and Development
The provision of patient care in healthcare is a very challenging and dynamic profession. Therefore, each
proponent organization shall ensure that their facilities employees have the knowledge, skills, ability and
behavior required to perform task(s) correctly and skillfully in order to provide quality care to all patients.
Since employees are required to demonstrate their competency levels, the facility must conduct competency
assessment before the employee is assigned to the task(s) and on an annual basis.
A training plan shall be developed based on individual assessment outcome(s).
Assessing the knowledge, skills, and abilities of an employee requires more than the use of a checklist and a
test. It entails the assessment, maintenance, demonstration, tracking, and improving/correcting the
competence of the target staff. As an ongoing process, competency assessment must have the initial
development, maintenance of knowledge and skills, educational/training sessions and correction of the
deficiency.
The Staff Competency program is a comprehensive program that begins with the hiring of competent staff
and continues with a competency-based orientation. This is made up of general orientation competencies,
specific competencies, mandatory and annual competencies. Continuing education and annual competency
evaluation of healthcare providers provides a means of improving and reinforcing their abilities.
General Competencies are competencies which are common to all medical positions in the remote
area clinics (RACs) and which start at the education unit and continue in the assigned medical facility.
Specific Competencies are competencies which are unique to the facility where the nurse and other
healthcare providers are assigned. These include: Emergency skills competencies, ambulance equipment
familiarization and basic operation for ambulance drivers. This involves teaching new skills required to
perform the job safely and effectively.
Mandatory Competencies are topics of high importance and for which periodic training is mandatory
and without which employee cannot continue to practice, such as Basic Life Support (BLS) certification.
Annual Competencies are competencies based on each clinic needs and are mandatory for each
employee. These include fire safety, infection control, etc.
Competency Assessment and Development Guidelines

Proponent Organizations shall arrange for a qualified personnel to conduct staff competency assessments as
follows:
1. Conduct a competency assessment by completing a performance appraisal checklist prior to on-site
assignment. For more information, see pages 134-135.
2. Ensure new hires meet the minimum qualifications for clinical practice and that nurse demonstrates
competency in all privilege areas. The assignment to specified areas of clinical practice and the type of
frequency of clinical supervision is decided by the review of the employees background and experience.
3. Reevaluate the clinical competence factors, should a change in job function/assignment and/or a
new/additional area of practice be added.
4. Develop a training and development plan based on the results of individual evaluation(s) with specific
target dates for completion.
Competency Assessment and Development

ATTACHMENT 20
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132
Apply the following methods for correcting deficiencies, taking into account the extent and seriousness of
the determined deficiency:
a.
In-service education.
b.
Consultation.
c.
Change in type of supervision of employee.
d.
Change in clinical practice area.
5. Incorporate additional activities to assist in ensuring continued competence. These include: review of
approved nursing standards/practices, nurse's attendance of workshops/seminars for continuing
education and in-service education programs.
6. Maintain records of the completed plans/training in the personnel file.
ATTACHMENT 20
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133
Emergency Skills Competency Assessment

Competency Assessment
Employees Name: ______________________
NO.:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Position: ________________
Item to Assess - Nurse shows competency by demonstrating the following:
I.D. No.: ___________

YES
NO
Airway Management:
1-1
Able to use naso and oropharyngeal airway.
1-2
Able to use pocket mask and bag-valve mask resuscitator/ambu.
1-3
Able to perform suctioning.
1-4
Able to perform laryngeal mask airway (LMA) insertion.
1-5
Able to administer oxygen with different type of masks.
Able to administer basic life support (BLS).
Able to use automated external defibrillator (AED).
Electrocardiogram (ECG) Management:
4-1
Able to use a 12 lead ECG machine.
4-2
Able to differentiate between normal and abnormal rhythms.
Able to use an infusion pump.
Able to apply immobilization techniques (neck/limbs/spine).
Able to apply hare traction.
Able to use a Kendrick extrication device.
Able to manage external bleeding.
Able to administer Entonox.
Able to manage anaphylactic shock.
Able to manage acute chest pain chest pain protocol.
Able to manage the initial management of burns burn protocol.
Able to activate a disaster response.
Able to complete the pharmaceutical, drug familiarization program.
Yes Scores 7.1 Points
No Scores 0
Total Score
Note: Passing Score is 95%

Result:
Pass
Fail
Remarks:
Action Plan:
Action in the event of failure is to enroll the employee into the appropriate competency development program and
conduct a second competency assessment exactly one month from the initial assessment.
Employees Signature: ________________________________________
Date: ____________________
Supervisors Name: ___________________________________________
I.D. No.: __________________
Supervisors Signature: ________________________________________
Date: ____________________

ATTACHMENT 20
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134
Ambulance Driver Competency Assessment

Competency Assessment
Employees Name: ______________________
NO.:
1
2
3
4
5
6
7
8
9
10
Position: ________________
I.D. No.: ___________
Item to Assess - Driver shows competency by demonstrating the following:
YES
NO
Able to administer basic life support (BLS).

Able to administer first aid (FA).
Able to operate ambulance communication device(s).
Able to operate ambulance siren and flashing lights.
Able to perform basic operation of the following ambulance equipment:
5-1
Oxygen.
5-2
Suction machine.
5-3
Collapsible/other stretchers.
5-4
5-5
Hare traction.
Able to apply standard precautions.
Able to apply patient and scene safety.
Ambulance maintenance:
8-1
Able to properly clean the ambulance, interior and exterior.
8-2
Able to perform daily vehicle condition checks.
8-3
Able to conduct ambulance preventive maintenance.
Able to verbalize his role and responsibilities in the event of emergency/disaster response.
Safety: Management:
10-1 Able to apply general road safety/speed limits.
10-2 Able to appropriately use safety triangle.
Yes Scores 10 Points
No Scores 0
Total Score
Note: Passing Score is 90%

Result:
Pass
Fail
Remarks:
Action Plan:
Action in the event of failure is to enroll the employee into the appropriate competency development program and
conduct a second competency assessment exactly one month from the initial assessment.
Employees Signature: ________________________________________
Date: ____________________
Supervisors Name: ___________________________________________
I.D. No.: __________________
Supervisors Signature: ________________________________________
Date: ____________________

ATTACHMENT 20
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135
Employee Orientation
Orientation is a comprehensive process that introduces new hires to the organization and to their roles and
responsibilities within the facility.
Types of Orientation
1. General Orientation
2. Unit/Area-Specific Orientation
General Orientation Benefits:
1. Helps new hires adapt and perform well in their jobs by providing them with a general orientation to
their organization/facility and his/her role in it.
2. Welcomes new hires to facility and promotes a positive attitude at the start of their employment.
3. Helps new hires develop pride in the facility, by explaining the goals, responsibilities, mission and vision in
providing excellent patient care.
4. Familiarizes new employees with the facilitys structure and lines and forms of communication within the
system. Effective two-way communication is stressed so that participants will know where to go with
questions, concerns and suggestions.
5. Provides new hires with information they should know from the start of their employment.
Core Elements of General Orientation include but are not limited to:
1. Infection Control.
2. Environment of Care Program (security, fire, Hazmat, disaster, etc.).
3. Confidentiality/privacy of health/patient information.
4. Patients Rights and Responsibilities.
5. Organizations Mission and Vision, operation, organizational chart and chain of command.
6. Reporting occurrences/incident.
7. Official forms of communication (policies and procedures, operating manuals, etc.).
8. Prevention of injuries in the work place.
9. Familiarization of new employees with general work rules and contract agreement as applicable.
When Should New Hires Receive General Orientation?
New hires shall be provided with general orientation during their first month of employment.
Unit/Area-Specific Orientation
An on-site specific orientation designed to introduce the new nurses to their new work environment, area
of medical response, local policies and procedures and the day-to-day specific activities of the facility they are
assigned to.
Unit/Area-Specific Benefits:
1. Introduces new employees to all aspects of the work.
2. Provides job-specific orientation to the individuals specific job description, provided in his/her assigned
area.
3. Helps new employees become acquainted with the correct way to perform their job and help him/her
know what to expect and what is expected of him/her in their new job.
4. Acquaints new employees with individuals and resources available to help them perform their jobs more
effectively.
ATTACHMENT 21
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136
Core Elements of Unit/Area Specific Orientation include but are not limited to:
1. Job responsibilities and work practices.
2. Facilitys policies and procedures.
3. Necessary requirements to maintain professional status.
4. Work schedule and work distribution.
5. Environment of Care Program:
a.
Disaster Plan.
b. Fire safety and fire plan.

c.
Equipment handling safety.
d. Material Safety Data Sheets (MSDS).

e.
Preventive maintenance.
f.
Occurrence reporting.
6. Quality Improvement Activities:

a.
QI/QA/QC programs.
b. Annual Competency requirements.

c.
Performance appraisals.
7. General infection control practices:

a.
Cleaning.
b. Waste management.
c.
Personal protective equipment (PPE).
d. Standard precautions.
e.
Hand washing.
ATTACHMENT 21
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137
Ambulance Driver Specific Orientation

All items listed below shall be completed within two (2) weeks of site assignment, except for items marked
with an asterisk (*), which must be successfully completed prior to site assignment.
The company will implement and administer an ambulance driver orientation and competency program to
include the following:
Item
Minimum Requirements
1.
Facility orientation.
2.
Work site orientation.
3.
*First aid.
4.
*Basic Life Support (BLS).
Date Completed
Remarks
Basic Ambulance operation:

5.
a.
Use of communication device.
b.
Use of siren and flashing lights.
Ambulance equipment familiarization and

basic operation:
6.
a.
Oxygen.
b.
Suction machine.
c.
Collapsible/other stretchers.
d.
e.
Hare traction.
f.
Other.
7.
Standard precautions.
8.
Patient and scene safety.

Ambulance maintenance:
9.
10.
a.
Cleaning.
b.
Daily vehicle condition checks.
c.
Preventing maintenance schedule.
Emergency/disaster response, role and

responsibilities.
Safety:
11.
12.
a.
General road safety/speed limits.
b.
Use of safety triangle.
Other.
Employee Orientation - Ambulance Driver
ATTACHMENT 21
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Continuing Education and Training

Education and training provide employees with the knowledge and skills necessary to provide a high standard
of patient care.
Types of Education and Training Programs
1. Ongoing Education and Training
2. Continuing Education (CE)
Ongoing Education and Training
Ongoing orientation and training is a continuing periodic program, which provides educational and training
activities necessary to meet the mandatory health and safety requirements, such as for fire safety and
infection control. These training activities must be organized jointly with infection control and fire safety
subject matter experts (SMEs) and/or other services as applicable. The following educational activities are
required as specified:
1. Infection control and fire safety, annually.
2. Resuscitation techniques, Basic Life Support and first aid, every two years.
3. Environment of Care Program (security, Hazmat (Hazardous materials/waste), disaster, etc.), annually.
4. When applicable, staff shall be trained to ensure proper, efficient and safe use of equipment/tools.
Note: All educational activities shall be documented in the employees personnel record as applicable.
Continuing Education (CE)
Continuing education refers to the provision of special education necessary to either obtain credits required
to maintain a license, or as means to acquire additional certification(s). Continuous learning and education is
required to stay abreast of new developments in the relevant field, enhance personal knowledge and skills,
and to serve patients most effectively.
Purpose
The CE program is intended to maintain and improve the knowledge and skills of certified healthcare
providers (i.e., nurses, doctors), therefore enhancing the quality of service provided to patients. Therefore, it is
necessary that every proponent organization establish a CE service design to provide administrative oversight
and program coordination for continuing education.
Benefits of Establishing a Continuing Education Program
1. Promote professional development.
2. Enhance clinical skills and practice behaviors required for excellence in patient care.
3. Enrich knowledge.
4. Support the medical and nursing profession.
Channels Which Provide CE include:
1. In-Services Program: Designed to provide classes on general requirements.
2. Conferences and Symposiums are planned, publicized gatherings that provide professional staff with the
opportunity to share information and to network.
3. Web-based programs.
4. Education brings this learning into the work area to facilitate learning at the staffs own pace, at their
own time and at their own convenience. With a wide range of courses, tests and exams offered online,
staff can develop their skills and gain certifications quickly and easily. Visit the following Web sites for
more information:
x
x
www.worldwidelearn.com/continuing-education/nursing-ce.htm
www.worldwidelearn.com/continuing-education/physicians-cme.htm
Continuing Education (CE)

ATTACHMENT 22
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139
First Aid Kit

First Aid Kit (36 unit size) shall be available with the following supplies.
SAP
Material
No.:
Description
1000132516
Bandage: Compress, 5 cm.
1000132519
Bandage: Compress, 10 cm.
1000132543
Bandage: Gauze.
1000132547
Bandage: Plastic, adhesive.
1000132600
Bandage: Triangular.
1000132605
Cold pack.
1000132609
Compress: Gauze.
1000132612
Forceps and scissors.
1000132615
Iodine: PVP ampule.
1000132618
Green soap swab.
1000132641
Tourniquet.
1000132169
First aid booklet, Arabic.
1000132180
First aid booklet, English.
Remarks
Safety Devices
At a minimum, the following safety devices shall be available:
SAP
Material
No:
Description
1000128476
Rescue type stretcher.
1000128490
Splint stretcher.
1000124087
Fire blanket.
Remarks
First Aid Kit

ATTACHMENT 23
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First Aid Kit

Description
SAP Material No:

1000128476
Rescue Type Stretcher
Rescue Type Stretcher

Folding; synthetic with nonferrous alloy supports; foam filled pad; capable of carrying patient in any position; 1,829
millimeter (72 inch) long and 245 millimeter (10 inch) wide.
Issue Restriction: None
Old Stock Number: 21-372-837
1000128490
Splint Stretcher
Splint Stretcher
Basket type litter; wire netting reinforced with iron braces; 4 straps; to carry patient in any position without danger;
stokes pattern; 2.1 meter (6.75 feet) long; 610 millimeter (24 inch) width; 216 millimeter (8.5 inch) height.
1000124087
Fire Blanket
Fire Blanket
Fire Blanket: 1,574.8 millimeter (62 inch) width by 2,082.8 millimeter (82 inch) long; flame proofed wool, pleated and
grommeted, with steel case, window in case and a fireproofed loop rope. Not suitable for use as a welding fire blanket.
This roller mounted blanket is intended to protect the body from extreme heat while exiting a fire area. This blanket can
also be used for self-extinguishment of clothing fires.
1000124087
First Aid Kit (10 unit size)

First Aid Kit (10 unit size); white finish; includes the following components listed in the Aramco Material Stock (AMS)
Catalog; complete in steel carrying case approximately 22 centimeter by 15 centimeter by 8.3 centimeter.
Per ANSI Z308.1-1978. PKS description SAMS 1 bandage: compress, 5 cm S/N 21-586-505 one (1) bandage: compress,
10 cm S/N 21-586-507 three (3) bandage: Plastic adhesive S/N 21-586-511 two (2) bandage: Triangular S/N 21-586-513
one (1) compress: Gauze S/N 21-586-519 one (1) iodine: PVP ampules S/N 21-586-529 one (1) Soap S/N 21-586-533.
1000124087

First Aid Kit (36 unit size); white finish; includes the following components listed in the Aramco Material Stock (AMS)
Catalog; complete in steel carrying case approximately 36 centimeter by 27 centimeter by 8.3 centimeter.
Per ANSI Z308.1-1978. PKS description SAMS 3 bandage: compress, 5 cm 21-586-505 five (5) bandage: compress, 10 cm
21-586-507 three (3) bandage: Gauze 21-586-509 six (6) bandage: Plastic, adhesive 21-586-511 three (3) bandage:
Triangular 21-586-513 four (4) cold pack 21-586-513 three (3) compress: Gauze 21-586-519 one (1) forceps and scissors
21-586-523 three (3) iodine: PVP ampules 21-586-529 one (1) Tourniquet 21-586-560.
First Aid Kit
ATTACHMENT 23
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141
First Aid Kit

Description
SAP Material No:

1000132516
Bandage: Compress, 5 cm
Bandage: compress; per ANSI Z308.1-1978; 5 cm square non-adherent; packaged; in 1 unit size package; 4 per package.
1000132519
Bandage: compress; per ANSI Z308.1-1978; 10 cm square non-adherent; packaged; in 1 unit size package; 1 per
package.
1000132543
Bandage: Gauze
Bandage: Gauze
Bandage: gauze roller; per ANSI Z308.1-1978; 5 cm x 550 cm; packaged in 1 unit size package; 2 per package.
1000132547
Bandage: Plastic, Adhesive
Bandage: Plastic, Adhesive

Bandage: plastic adhesive; per ANSI Z308.1-1978; 2.5 cm x 7.5 cm; packaged in 1 unit size package; 16 per package.
1000132600
Bandage: Triangular
Bandage: Triangular
Bandage: triangular; sterile; per ANSI Z308.1-1978; 100 cm x 100 cm x 140 cm; packaged in 1 unit size package; 1 per
package.
1000132605
Cold Pack
Cold Pack
Cold Pack: in plastic pouch with chemicals in two sections that provide a cold chemical reaction when squeezed;
packaged in 1 unit size package; 1 per package per ANSI Z308.1-1978; 1 per package.
1000132609
Compress: Gauze
Compress: Gauze
Compress: gauze per ANSI Z308.1-1978; 60 cm x 180 cm; packaged in 1 unit size package; 1 per package.
First Aid Kit
ATTACHMENT 23
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142
First Aid Kit

Description
SAP Material No:

1000132612
Forceps and Scissors
Forceps and Scissors

Forceps and scissors: steel, sharp, pointed forceps; blunt nosed; steel scissors for cutting gauze; packaged in 1 unit size
package; 1 per package per ANSI Z308.1-1978; 1 each per package.
1000132615
Iodine: PVP Ampules
Iodine: PVP Ampules

Iodine: PVP (Polyvinyl Povidone); crushable ampules filled with 0.5 cc PVP Iodine with cotton-tipped applicator
at one end; packaged in 1 unit size package per ANSI Z308.1-1978; 10 per package.
1000132618
Green Soap Swabs
Green Soap Swabs

Swabs: Green Soap crushable; 0.5 ml; width 2 x 51 mm (2 inch) gauze pad.
1000132641
Tourniquet
Tourniquet
Tourniquet: per ANSI Z308.1-1978; supplied with a separate card to note the time tourniquet was applied and the
location of tourniquet; packaged in 1 unit size package; 1 per package.
1000132600
First Aid Booklet (Arabic)
First Aid Booklet (Arabic)

Subjects: bleeding, bandaging, splinting, resuscitation, heat stroke, heat exhaustion and poisoning: Author - Asmund S.
Laerdal, Stavanger.
1000132169
First Aid Booklet (English)
First Aid Booklet (English)

Subjects: bleeding, bandaging, splinting, resuscitation, heat stroke, heat exhaustion and poisoning: Author - Asmund S.
Laerdal, Stavanger.
First Aid Kit

ATTACHMENT 23
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First Aid Cabinet and Contents

Specification:
1. Must be no less than 85 cm long x 45 cm width x 30 cm diameter.
2. Must be made of hard wood or metal and be provided with a lock and the Red Crescent insignia and the
words First Aid Cabinet.
3. Must be ready for use and accessible at all times.
4. Must be restocked up after each use.
Number
List of Contents
Unit
Quantity
Each
2 of Each
100 Box
1 Box
Pair
2 of Each
100 Box
2 Box
Oral Airways, medium and large.
Non-sterile exam gloves.
Sterile gloves, sizes: 7.5 and 8.
Band aids.
Alcohol swabs.
100 Box
100 Box
Iodine swabs.
100 Box
1 Box
Tube
1 Tube
2 x 2 (5 cm x 5 cm) sterile gauze.
12 Packet Box
1 Box
4 x 4 (10 cm x 10 cm) sterile gauze.
12 Packet Box
1 Box
10
Roller gauze, sizes: 2, 3 and 4 inch.
Roll
3 Rolls of Each
11
Adhesive tape roll, 1 inch.
Roll
2 Rolls
12
Eye Pad.
6 Box
1 Box
13
Ace Bandage, sizes: 2, 3, 4 and 6 inch.
Each
4 of Each
14
Triangular bandage.
Each
Six (6)
15
Safety pins.
Each
Twelve (12)
16
Bandage scissors.
Each
One (1)
17
Burn sheet.
Each
Four (4)
18
Abdominal dressing pad, 5 inch x 9 inch.
6 Box
19
Multi-trauma dressing pad.
Each
Four (4)
20
Cold pack.
Each
2 Packet
21
Ammonia inhalant.
6 Box
1 Box
22
Padded arm board.
Each
Four (4)
1 Box
First Aid Cabinet and Contents

ATTACHMENT 24
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Policies and Procedures

Policies and procedures are facility specific instructions and guidelines regarding the day-to-day
activities/operation of the medical facility.
General Guidelines
1. Each organization is responsible for developing specific policies and procedures for its medical facility.
These policies must be updated and revised every three (3) years. Revisions are approved by an
authorized medical representative, and dated to identify the review date.
2. Policies and procedures shall be available to all concern staff. These policies include but are not limited
to:
General Guidelines
Required Policies and Procedures
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Organization:
1-1
Organization Chart.
1-2
Roles and Responsibilities.
1-3
Mission and Vision.
Administrative:
2-1
Job descriptions.
2-2
Manpower Requirements.
2-3
Staff Qualifications.
2-4
Staff Recruitment Process.
2-5
Licensing.
Staff Education Program:
3-1
New Hire Orientation.
3-2
Staff Competency.
Safety and Loss Prevention:
2-1
Fire Safety.
2-2
HAZCOM.
2-3
Disaster Response Plan.
Infection Control and Environmental Health.
Quality Improvement Program.
Operation:
6-1
Scope of Service.
6-2
Patient Eligibility of Care.
6-3
Patient Registration and Health Insurance.
6-4
Consultation.
6-5
Referral and Transfer.
Medical Records Patient, Documentation and Confidentiality of Information.
Patient Care/Nursing Practice.
Treatment Protocol.
Equipment Management and Supplies.
Drugs: prescription, ordering, storage, administration, dispensing, shipping and receiving of drugs.
Communication.
Transportation: Patients transfer and Medivac Procedures.
Laboratory specimens: handling, storage and transportation.
Note: Should you require a sample of any of the above policies, please contact the Remote Area Urgent Care
Facilities Group Leader. He can be contacted at 03-877-3459 or 03-877-3338.
Policies and Procedures
ATTACHMENT 25
Page 1 of 1
145
145
Floor
Plan
Specifications for
for Category
Facility
Floor
Plan
Specifications
CategoryC
C
Facility
Multiple rooms and integrated staff accommodation.
Floor Plan Specifications for Category C Facility

With central or split-level filtered air conditioning unit (A/C), covered ambulance parking and ramp for stretcher.
central or split-level filtered air conditioning unit (A/C), covered ambulance parking and ramp for stretcher.
WithWith
central
or split-level filtered air conditioning unit (A/C), covered ambulance parking and ramp for stretcher.
ATTACHMENT 26
Page 1 of 1
146
ATTACHMENT 26
Page 1 of 1 ATTACHMENT 26
146
146 Page 1 of 1
oor Plan Specifications for Rig Medical Facility

Floor Plan Specifications for Rig Medical Facility

ATTACHMENT 27
Page 1 of 1
147
ATTACHMENT 27
Page 1 of 1
147
147
Section 6 References
1. Saudi Labor and Workmen Law, Chapter 7.
2. Saudi Aramco Safety Manual, Section 28.
3. Saudi Aramco GI 1321.015 and GI.150.002.
4. Saudi Aramco Medical Services Organization/Healthcare Development Organization, Infection
Control Manual.
5. Saudi Aramco Medical Services Organizations Medical Services Policies (MSPs) and
Operating Manuals (OMs).
148
148
Section 7 Appreciation
Our thanks and appreciation to the following subject matter experts (SMEs) for their valuable
contribution to this manual:
x
Ali Hammoud, QI Advisor, Remote Area Clinics Group/Medical Consulting and Quality
Assurance Division (MC&QAD)/Medical Designated Facilities Department (MDFD)/Healthcare
Development Organization (HDO)/Saudi Aramco Medical Services Organization (SAMSO).
Curtis Roberts, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
Eduarte B. Cocos, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
George Williamson, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
Hamed J. Said, Group Leader, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
Janet R. Acevedo, Health Educator, Medical Professional and Technical Support/MC&QAD/

MDFD/ HDO/ SAMSO, for collating this manual.
Dr. Hatem K. Herzallah, Unit Head, Medical Professional and Technical Support/MC&QAD/
MDFD/ HDO/ SAMSO, for allocating the time for the collation of this manual.
Russel Isaiah, QI Advisor, Remote Area Clinics Group/ Remote Area Clinics Group/MC&QAD/
MDFD/ HDO/ SAMSO.
Ramesh Swaminathan, Administrative Assistant, Remote Area Clinics Group/MC&QAD/ MDFD/

HDO/ SAMSO, for all the time and effort and for the countless hours spent typing the initial
layout of this manual.
Terry Nihil, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
William McDowall, many thanks for all the help in putting together the first draft of this manual
and widely admired for his vast and unrivalled knowledge and experience in this field, for his
valuable input and diligent proofreading.
And our special thanks and appreciation to our distinguished Management (Dr. T.Q. Al-Daiel, Dr.
Saad A. Missmar and Dr. Mohd Fawzy Younis), without whom this manual would not have been
possible.
Sincerely,
_______________________________________
Jacques D. Cheong, Quality Assurance
Coordinator
149
149

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HEALTHCARE DEVELOPMENT ORGANIZATION

Medical Designated Facilities Department

Remote Area Clinic Group

Remote Area Urgent Care Facilities

Healthcare Development Organization

Remote Area Urgent Care Facilities Group

June 14, 2009

Jacques D. Cheong, Quality Assurance Coordinator

Dr. Mohd Fawzy Younis, Chief

Dr. Saad A. Missmar, Director

Dr. T.Q. Al-Daiel, General Manager

Areas over open water.

Section 2 Initial Category/Level Evaluation

Name of Medical Facility: ____________________

Name of Company: __________________________________________________

Employee population exceeds 50 workers in a single location

Complete Section 13 of the Survey and Compliance Review Report

Complete Section 23 of the Survey and Compliance Review Report

Complete Section 3 of the Survey and Compliance Review Report

Complete Section 4 of the Survey and Compliance Review Report

Name of Assessor: __________________________________________________________

HEALTH CARE PROVISIONS AT REMOTE LOCATIONS

Every contracting company which operates within Saudi Aramco remote

An employer who employs less than fifty (50) workmen shall

An employer who employs fifty (50) or more laborers at a

A first aid room at the work site. Depending on

A Saudi MOH licensed nurse shall be on duty 24

Every proponent organization shall have a copy of the MMSR manual at

Every proponent organization shall provide healthcare as per the

There is evidence that all employees, including subcontractor

NO = Does not Meet Standards

SURVEY AND COMPLIANCE REVIEW REPORT

HEALTH CARE PROVISIONS AT REMOTE LOCATIONS (Cont.)

There is evidence that all employees and subcontractor

There is evidence that the organization designated an inpatient

There is evidence that the organization maintains adequate

Every proponent organization shall have a database system that at a

Employees medical registration (MR) number.

Name of Medical Facility.

Medical insurance card number and level of medical coverage.

Proponent organization head office contact number.

Proponent organization 24 hour on-site representative contact

Contact number of Saudi Aramco Supervisor overseeing the

All information above is kept current at all times.

NO = Does not Meet Standards

SURVEY AND COMPLIANCE REVIEW REPORT

HEALTH CARE PROVISIONS AT REMOTE LOCATIONS (Cont.)

Every proponent organization at a minimum shall define their

A vision, a statement about what the organization wants to

A mission, an organization's vision translated into written

Basic Life Support (BLS).

First Aid (FA).

Mission statement is posted.

Vision statement is posted.

Current certificate available upon request.

Every proponent organization shall ensure that their medical facilities

Saudi Council for Health Specialties (SCFHS).

Ministry of Health (MOH).

NO = Does not Meet Standards

SURVEY AND COMPLIANCE REVIEW REPORT

2.A General Standards

Writing/information is clear and concise.

At a minimum it contains the following information/details in

Staff availability including regular and emergency