"IMPROVEMENT OF THE CALLALLI HEALTH CENTER, CALLALLI DISTRICT - CAYLLOMA - AREQUIPA".

FUNCTIONAL MEDICAL PROGRAM

PMF

TECHNICAL FILE: "IMPROVEMENT OF THE CALLALLI

HEALTH CENTER, CALLALLI DISTRICT - CAYLLOMA

- AREQUIPA".

AREQUIPA, PERU

2020

ELABORATED REVIEWED APPROVED DATE

Arch. Cristian Berrios

CAP 16355 AREA SUPERVISOR PROJECT COORDINATOR

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I. PURPOSE:
Strengthen the governing role of the Southern Health Directorate within its health jurisdiction.

II. AIM:
Establish the administrative framework for the preparation and presentation of the technical file, to
request a Directorial Resolution for the creation of the establishment, CALLALLI HEALTH
CENTER CATEGORY I – 4 .

III. AREA OF APPLICATION:

Mandatory application in the Directorates, Offices, Networks, Micro networks and establishments of
category I – 4 level of care, belonging to the Ministry of Health, within the health jurisdiction.

IV. LEGAL BASE:

1. Law No. 26842, General Health Law.
2. Law No. 27444, General Administrative Procedure Law.
3. Supreme Decree No. 013-2006-SA, which approved the Regulations for Health
Establishments and Medical Support Services.
4. Supreme Decree No. 096-2007-PCM, which regulates the subsequent random inspection of
administrative procedures by the State.
5. Ministerial Resolution No. 751-2004/MINSA, which approved Technical Standard No. 018-
MINSA/DGSP-V.01 called: “Technical Standard for the Reference and Counter-Reference
System of Health Establishments of the Ministry of Health.”
6. Ministerial Resolution No. 769-2004/MINSA, which approved Technical Standard No. 021-
MINSA / DGSP / V.01: “Categories of establishments in the health sector.”
7. Ministerial Resolution No. 1142-2004/MINSA, which approved “Guide for the categorization of
health facilities in the health sector.”
8. Ministerial Resolution No. 588-2005/MINSA, which approved the lists of basic biomedical
equipment for health establishments of the first, second and third level of care.
9. Ministerial Resolution No. 970-2005/MINSA, which approved NTS No. 038-MINSA/DGSP-
V.01: “Technical Health Standard for Architecture, Equipment and Furniture Projects of Health
Establishments of the First Level of Care.”
10. Ministerial Resolution No. 341-2006/MINSA, which approved “Regulations of Organization
and Functions of the Health Directorate II Lima Sur”.

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V. GENERAL DISPOSITION:

5.1. OPERATIONAL DEFINITIONS:

For this purpose, the following operational definitions will be considered:

5.1.1 HEALTH ESTABLISHMENT: It is the operational unit of the offer of health services
implemented with human resources, materials and equipment; Responsible for executing care
and administrative activities.

5.1.2 LEVEL OF COMPLEXITY: It is the degree of differentiation and development of health

services, achieved thanks to the specialization and modernization of their resources. It is related
to the categories of health establishments.

 1st level of complexity: I-1

 2nd level of complexity: I-2
 3rd level of complexity: I-3
 4th level of complexity: I-4
 5th level of complexity: II-1
 6th level of complexity: II-2
 7th level of complexity: III-1
 8th level of complexity: III-2

The project: "IMPROVEMENT OF THE CALLALLI HEALTH CENTER, CALLALLI DISTRICT -

CAYLLOMA - AREQUIPA". It corresponds to the 4th level of complexity: I-4.

5.1.3 CATEGORY: It is the condition assumed by a health establishment based on its functions,
characteristics and level of complexity, which responds to its socio-health reality and is designed
to face equivalent demands.
o Category I-1 : Health post without doctor.
o Category I-2 : Health post with doctor.
o Category I-3 : Health center without hospitalization.
o Category I-4 : Health center with admission.
o Category II-1 : Hospital I.
o Category II-2 : Hospital II.
o Category III-1 : Hospital III.
o Category III-2 : Specialized institute.

The project: "IMPROVEMENT OF THE CALLALLI HEALTH CENTER, CALLALLI DISTRICT -

CAYLLOMA - AREQUIPA". It corresponds to the Health Center with category I-4 confinement.

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5.1.4 LEVEL OF CARE: Set of health facilities with levels of complexity necessary to effectively
and efficiently resolve health needs of different magnitude and severity.
o First level of care : Includes categories from I-1 to I-4.
o Second level of care: Includes categories II-1 and II-2.
o Third level of care : Includes categories III-1 and III-2.

The project: "IMPROVEMENT OF THE CALLALLI HEALTH CENTER, CALLALLI DISTRICT -

CAYLLOMA - AREQUIPA". It corresponds to the First level of care.

5.1.5 FIRST LEVEL OF CARE: It constitutes the population's first contact with health services;
Its main activities are aimed at promotion, prevention, medical care, epidemiological surveillance
and health recovery activities, according to the category granted. Its providers are made up of the
Basic Comprehensive Care Team and the services are offered intra- or extra-murally (at home,
community level, in educational establishments, in general medicine outpatient clinics, in health
centers and posts, in community clinics and eventually in work centers).

The care actions for people are fundamentally outpatient in nature, with emphasis on the clinical
and epidemiological method with the support of complementary basic diagnostic techniques.

5.1.6 COVERAGE OF CARE ACCORDING TO LEVEL: Health establishments, according to

the level of care to which they are assigned, must support a percentage of the demand for health
services, as follows:

 The first level of care, also called local level, covers 70 to 80% of health demand, with low
complexity.

5.1.7 SERVICE PRODUCING UNIT (UPS): It is the basic unit of health supply, constituted by the
set of human, physical and technological resources, organized to determine homogeneous
functions and produce health services, in relation to their complexity.

5.1.8 HEALTH ESTABLISHMENT WITH INTERNSHIP: These are those health establishments
that provide comprehensive, general or specialized care to acute or chronic patients, and that, to
perform clinical or surgical care or procedures, for diagnostic, therapeutic or rehabilitation
purposes, require permanence and necessity. of care support for more than twelve (12) hours due
to their degree of dependency or risk. Health facilities with confinement can be:
- Hospitals or general care clinics.
- Hospitals or specialized care clinics.
- Health centers with hospital beds.
- Geriatric care centers.
- Specialized health institutes.

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VI. SPECIFIC PROVISIONS:

6.1. OF THE REQUIREMENTS FOR THE PREPARATION OF THE TECHNICAL FILE

TO REQUEST A RESOLUTION FOR THE CREATION OF FIRST LEVEL OF
CARE FACILITIES OF THE MINISTRY OF HEALTH.

REQUIREMENTS FOR THE PREPARATION OF THE TECHNICAL FILE TO

No REQUEST A RESOLUTION FOR THE CREATION OF ESTABLISHMENTS OF THE
. FIRST
LEVEL OF ATTENTION
Letter signed by the Executive Director of the Network, addressed to the General
1 Director of DISA II LS, requesting a Directorial Resolution to create a health
establishment.
2 Copy of the document that certifies the legal status of the land.
3 Functional medical plan.
Report on approval of architectural plans by the Executive Office of Strategic
4
Planning of DISA II LS (*).
List of biomedical equipment and furniture by service, differentiating those
5 own from those provided by third parties (See annexes No. 3 and 4).
6 Sketch or location map of the health facility. (Annex No. 5).
Distribution sketch of areas and services of the health establishment (metrado),
7
see Annex No. 6.
8 Civil defense security certificate, granted by INDECI or Municipality.
Affidavit of date of start of activities of the health establishment. Annex No. 7
9
Copies of electricity and water bills, or sworn statement that the
10 health facility has electricity, water and drainage. (See annex No. 8)
11 Number of mobile units for patient transfer. (Annex No. 9)
12 Services portfolio. (Annex No. 10)
13 Map of reference and counter-reference flows. (Annex No. 11)
14 Simple copies of the professional title, tuition, specialty registration (if any) and
updated work ability of the Medical Director, Chief Physician or Person Responsible
for care.
15 Simple copies of the professional titles and tuition of the health establishment's
professional staff.
16 Simple copies of the DNI of non-professional staff.

(*) In the case of infrastructures already built (donated, as a transfer or other modality), this
document must be replaced by the civil defense security certificate, granted by INDECI or the
respective Municipality.

6.2. OF THE DOCUMENTS FOR THE PREPARATION OF THE TECHNICAL FILE:

6.2.1 OFFICE SIGNED BY THE EXECUTIVE DIRECTOR OF THE NETWORK,

requesting a Directorial Resolution to create a health facility.

6.2.2 COPY OF THE DOCUMENT THAT CREDITS THE LEGAL SITUATION OF THE
LAND: A copy of the property title registered in the Public Registries of Lima in the
name of the Ministry of Health, a document of donation of the land in the name of
the Ministry of Health, Mayor's Resolution and minutes of Council agreement
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agreeing to the donation of the land in favor of the Ministry of Health, document of
donation of infrastructure and land of the Community, NGO or Cooperator in favor
of the Ministry of Health, possession or administration agreement, rental contract,
etc

6.2.3 FUNCTIONAL MEDICAL PLAN, which must have the following structure:

[Link] INTRODUCTION: Summary of the content of the document, which

emphasizes the mission, vision and services to be offered. The type of care
must be indicated (outpatient or inpatient) and include the benefit that the user
population will obtain when starting their activities.

[Link] GENERAL OBJECTIVE/S: It can be one or several; It must be concrete and

direct: “Provide specialized outpatient care to pregnant women”; “Provide
recuperative care to older adults”, etc.

[Link] SPECIFIC OBJECTIVES: They generally reveal the ways in which the general
objective will be achieved.

[Link] TARGET POPULATION WHO WILL BE SERVED:

- For public facilities, the target population is the institutionally
assigned general population.

[Link] HEALTH ESTABLISHMENT DATA:

- NAME OF THE ESTABLISHMENT: Enter the name with which the

health establishment will be identified: “Renacer Health Post”,
“Renacer Health Center”, “Renacer Maternal and Child Center”, etc.

- ADDRESS OF THE ESTABLISHMENT. Enter the exact address

where the health facility is located.

- TELEPHONE: Register the landline telephone number of the health

establishment.

- HOURS OF ATTENTION: Indicate the days and hours of service to

the public:
 Monday to Sunday from 08:00 – 20:00 hours.
 Monday – Wednesday – Friday from 4:00 p.m. to 10:00 p.m.
 Monday to Sunday, 24 hours a day.

- NAME OF THE MICRONETWORK TO WHICH IT BELONGS, the

name of the Micronetwork to which the health establishment will belong
must be entered.

- ASSIGNED HEALTH JURISDICTION: The geographical area that the

corresponding Directorate or Office of the Network has assigned to the
new health establishment must be indicated, and must include the
name of the localities, communities and human settlements, etc.,
assigned to it.

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- POPULATION ASSIGNED BY THE NETWORK: The total population

that the corresponding Directorate or Office of the Network has
assigned to the new health establishment must be indicated; each one
being discriminated according to the localities, communities, human
settlements, etc., of the assigned health jurisdiction.

- NAME OF THE ESTABLISHMENT TO WHICH IT REFERS, indicate

the name of the health establishment(s) to which it will be referred, for
outpatient consultation, diagnostic and emergency support, indicating
the category of each of them. In the event that it is only one health
establishment that will resolve all reference problems, only the name of
that establishment will be registered, indicating that all references will
be concentrated there.

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[Link] HEALTH PROFESSIONAL RESPONSIBLE FOR CARE: Enter the names and
surnames of the Medical Director, Chief Physician or professional responsible
for patient care; You must indicate the identification document number (DNI),
Professional Association (CMP, COP, CEP, etc.), Specialty Registration if you
have it (RNE); home, landline and cell phone.

[Link] NAME OF THE LEGAL REPRESENTATIVE: Enter the information of the

Executive Director of the Network, to which the health establishment is
attached. The same data that was registered for the responsible professional
must be entered: names and surnames, DNI, Professional Association,
Specialty Registration (if applicable), address, landline and cell phone.

[Link] LEGAL ADDRESS, enter the address where the Executive Directorate of the
Network is located.

[Link] LIST OF HUMAN RESOURCES (professional and non-professional): The total

human resource that carries out activities in the health establishment or
medical support service must be listed, as shown in Annex No. 1.

[Link] SERVICES TO BE OFFER: Number and detail all the services and the
schedules in which these will be offered, including medical specialties and
diagnostic support services: General Medicine, Gynecology, Obstetrics,
Pediatrics, General Surgery, Dentistry, Psychology, Nutrition, Care of Births,
Hospitalization, Emergency, pharmacy, X-rays, MRI, CT, Ultrasound;
Laboratory; etc

[Link] NUMBER AND DISTRIBUTION OF ROOMS BY FLOORS: As indicated in

Annex No. 2.

[Link] LIST OF BIOMEDICAL EQUIPMENT AND FURNITURE PER SERVICE,

DIFFERENTIATING THOSE OWN FROM THOSE PROVIDED BY THIRD
PARTIES: See annexes Nos. 3, 4 and 13.

[Link] FLOW OF CARE ACCORDING TO SERVICES: flow charts must be prepared

of the routes that patients follow to access care or service, even in cases of
referral or counter-referral.

6.2.4 REPORT ON APPROVAL OF ARCHITECTURAL PLANS BY THE EXECUTIVE

OFFICE OF STRATEGIC PLANNING OF THE DISA II LS: A simple copy of the
technical report of the Executive Office of Strategic Planning (OEPE) of the DISA II
LS must be included, through which it approves the plans architectural features of
the establishment to be created.

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6.2.5 SKETCH OR LOCATION MAP OF HEALTH FACILITY: Include a graph that allows
the quick location of the establishment, including reference points that facilitate
arrival there, as shown in Annex No. 5.

6.2.6 DISTRIBUTION DISTRIBUTION SKETCH OF AREAS AND SERVICES OF THE

HEALTH ESTABLISHMENT (measurement): A graph must be included that shows
the distribution of the environments, recording their dimensions (measurement), as
shown in Annex No. 6.

6.2.7 CIVIL DEFENSE SECURITY CERTIFICATE: Regardless of the size of the

establishment, this can be requested from INDECI; In the case of small offices, it
can also be issued by the respective municipality.

6.2.8 AFFIDAVIT OF DATE OF START OF ACTIVITIES OF THE HEALTH

ESTABLISHMENT, signed by the Head of the health establishment and the
Executive Director of the network. Annex No. 7

6.2.9 COPY OF THE LIGHT AND WATER RECEIPTS, OR SWORN DECLARATION

stating that the health establishment has basic services. Annex No. 8

6.2.10 NUMBER OF MOBILE UNITS FOR TRANSFER OF PATIENTS, detail the number
and type of mobile units that the health establishment has for the transfer of
patients. Annex No. 9

6.2.11 SERVICES PORTFOLIO. Annex No. 10

6.2.12 MAP OF REFERENCE AND COUNTERREFERENCE FLOWS. The reference flow

map for outpatient consultation, diagnostic support, urgencies and emergencies
must be included. Annex No. 11.

6.2.13 SIMPLE COPIES OF THE PROFESSIONAL TITLE, TUITION REGISTRATION,

SPECIALTY REGISTRATION (IF ANY) AND updated WORK SKILLS of the
medical director, head physician or person responsible for care.

6.2.14 SIMPLE COPIES OF THE PROFESSIONAL TITLES AND TUITION OF THE

STAFF OF PROFESSIONALS OF THE HEALTH ESTABLISHMENT.

6.2.15 SIMPLE COPIES OF THE ID OF NON-PROFESSIONAL PERSONNEL.

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6.3. PROCEDURE FOR THE OBTAINING OF THE DIRECTORAL

RESOLUTION FOR CREATION OF THE HEALTH ESTABLISHMENT:

6.3.1 FROM FILE ENTRY :

[Link] The process begins with the presentation of the technical file, by the
Executive Directorate of the Network involved, before the Documentary
Processing Unit (table of parties) of the Health Directorate II Lima South
(DISA II LS),
[Link] The Document Processing Unit staff or whoever takes their place will receive
the file and assign it the corresponding number, sealing and signing the
receipt document.
[Link] Once the documentation is entered, it will follow the established
administrative flows, until reaching the Executive Directorate of People's
Health.

6.3.2 OF THE FILE EVALUATION:

[Link] The professional responsible for the public establishments of the Directorate
of Health Services (DSS), of the Executive Directorate of People's Health
(DESP), will evaluate the documentation contained in the technical file, which
must correspond to that indicated in the section 6.1.
[Link] If the file does not meet the required requirements and after communicating
with the interested party, five (05) business days will be given to complete it;
The deadline has expired and the documentation has not been regularized,
the file will be returned with the pertinent observations.
[Link] If the file complies with the required documentation or has been regularized,
the professional responsible for the DSS will proceed to coordinate with the
Executive Directorate of the Network, the date and time for the inspection
visit.

6.3.3 FROM THE INSPECTION VISIT:

[Link] Once the date and time of the inspection has been agreed, the person in
charge of the public establishments or representative of the DSS will appear
at the establishment for which the Directorial Resolution of creation was
requested.
[Link] The Executive Director of the Network or his representative and the Medical
Director, Chief Physician or professional responsible for the care of the health
establishment must participate in this act.
[Link] Once the formalities of the case have been completed, the DSS
representative will proceed to inspect the establishment to verify if the
information contained in the technical file agrees with what is found in reality.

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[Link] The inspection will be aimed at verifying compliance with regard to

documentation, environments, equipment, human resources and biosafety.
[Link] At the end of the inspection or during its execution, a report will be drawn up
in which the conformity or non-conformity of what was found will be recorded.
[Link] The minutes will be signed by the Executive Director of the Network or his
representative, the Medical Director, Chief Physician or professional
responsible for the care of the establishment and the person in charge of
public establishments or representative of the DSS, who carried out the
inspection; It may also be signed by other officials and/or workers who
participated in the event.
[Link] If any observation has been made or any non-conformity is found, which
delays the issuance of the Directorial Resolution, this will be indicated in the
minutes, granting a period of six (06) business days, for its lifting; Once the
deadline has expired, the file will be returned to the respective Network.
[Link] If everything is found to be in compliance or the observations or non-
conformities have been corrected, the DISA professional who carried out the
inspection will proceed to prepare the technical report.

6.3.4 OF THE TECHNICAL REPORT AND THE DIRECTORIAL CREATION RESOLUTION :

[Link] The DISA professional who carried out the inspection is responsible for
preparing the technical report, which will conclude with the suggestion of
whether or not to project the Directorial Resolution creating the health
establishment. Likewise, and if applicable, it will project the pertinent
Directorial Resolution.
[Link] Everything carried out (the technical approval report, the inspection report,
the draft Directorial Resolution and the technical file) will be submitted to the
Directorate of Health Services, the Executive Directorate of People's Health
and the Legal Advisory Office of the DISA II Lima Sur, for the corresponding
visa.
[Link] During this stage, the aforementioned Directorates and Offices will make the
pertinent observations, returning the documentation to the Health Service
Directorate, so that any deficiency or non-conformity detected can be
corrected.
[Link] Once the non-conformities have been raised or the deficiencies corrected,
each Directorate or Office will approve the Directorial Resolution of creation,
as established by the regulations of the Ministry of Health.

6.3.5 OF THE SIGNING OF THE DIRECTORAL CREATION RESOLUTION:

[Link] The draft Directorial Resolution, endorsed by the relevant Directorates and
Offices of the DISA II LS, together with the documentation indicated in section
[Link], will be submitted to the General Directorate for the corresponding
signature.

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[Link] Once the administrative procedures have been completed, the General
Director of the Health Directorate II Lima Sur will sign the Directorial
Resolution creating the health establishment, an act with which the DISA II
Lima Sur formally recognizes a new establishment within its health
jurisdiction.
[Link] The endorsed Directorial Resolution, with everything acted upon, is
transferred to the Executive Directorate of People's Health to be delivered to
the interested party.

6.4. OF THE DELIVERY OF THE DIRECTORAL RESOLUTION FOR THE CREATION

OF THE HEALTH ESTABLISHMENT:
6.4.1 The Executive Directorate of People's Health is responsible for delivering the
Directorial Resolution of creation to the Executive Directorate of the Network, to the
corresponding levels of the DISA II Lima Sur and the Ministry of Health.

VII. RESPONSIBILITIES:

7.1 The Executive Directorate of People's Health, through the Directorate of Health Services, is
responsible for the dissemination and monitoring of this Administrative Directive.
7.2 The officials of the Directorates and Offices of DISA II Lima Sur are responsible for
compliance with this Administrative Directive.
7.3 The Executive Directors of the Networks, Directors or Heads of Micronetworks and chief
physicians of the establishments of the Ministry of Health or whoever acts in their place, are
responsible for the dissemination, implementation, execution and compliance of this
Administrative Directive.

VIII. FINAL PROVISIONS:

8.1 If there is a need to correct any error in the Directorial Resolution delivered, this will be done
in accordance with the provisions of Law No. 27444, General Law of Administrative
Procedure.
8.2 The Executive Directorate of People's Health, through the Directorate of Health Services, as
established by the regulations for these cases, will archive the file that supported the
issuance of the Directorial Resolution creating the health establishment.
8.3 Once the Directorial Resolution of creation has been obtained, the Executive Directorate of
the Network will arrange for the preparation of the technical file to obtain the categorization
of the newly created establishment, which includes its registration in the National Registry of
Health Establishments and Medical Support Services. (RENAES).

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IX. ANNEXES

9.1 No. 1: Human resources relationship (professional and non-professional)

9.2 No. 2: Number and distribution of rooms by floor.
9.3 No. 3: List of biomedical equipment by service, differentiating those owned from those
provided by third parties
9.4 No. 4: List of furniture per service, differentiating between those provided by third parties
and those provided by third parties.
9.5 No. 5: Sketch or location map of the health establishment.
9.6 No. 6: Distribution sketch of areas and services of the health establishment (metrado).
9.7 No. 7: Model sworn declaration of the date of commencement of activities of the health
establishment.
9.8 No. 8: Model sworn declaration stating that the health facility has basic services
9.9 No. 9: Matrix model of the number of mobile units for land transfer of patients.
9.10 No. 10 Service portfolio model.
9.11 No. 11 Reference and counter-reference flow map model.
9.12 No. 12 Minimum equipment and supplies by UPS.

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care establishments of the Ministry of Health

ANNEX No. 1

RELATIONSHIP OF HUMAN RESOURCES (PROFESSIONAL AND NON-PROFESSIONAL)

Name of health facility:………………………………………………………………………………

Medical Director, Chief Physician or person responsible for care:………………………………………….

Date:………………………………………………………………………………………….

Profession Specialty
No. Names and surnames Profession Specialty Post ID number
al registration
association
Doctor
1. Juan Perez Perez Surgeon 0012 Pediatrician 0124 Medical director 12345678
Surgeo Head of gastroenterology
2. Rosa Huamán Quezada 0011 Gastroenterology 0408 87654321
n department
Doctor
3. Liz Villena Jara 0123 0578 Assistant physician 85476910
Surgeon
4. Juan Lopez Ruiz Nurse 0021 Assistant nurse 89756431
5. Manuel Chipana Vásquez Driver 77596421
6. Maintenance
7. Secretary
8. Surveillance

……………………………………………..

Medical Director, Chief Physician or

Person Responsible for Care

DNI N°……………………….

In the case of professional personnel, a simple copy of the degree, tuition and specialty registration (if applicable) must be attached; In the case of non-
professionals, attach a simple copy of the DNI.

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX No. 2

NUMBER AND DISTRIBUTION OF ROOMS BY FLOORS

Name of health facility:………………………………………………………………………………
Date:……………………………………

Area
Floor Area/service
(m2)
number
Waiting room

Admission

Triage
1 Public bathroom

Topical

Medicine office 1

Medicine office 2

2 Pediatric office 1

Gynecology office

Professional bathroom

Radiology
3
Laboratory

……………………………………………..

Medical Director, Chief Physician or

Person Responsible for Care

DNI N°……………………….

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care establishments of the Ministry of Health

ANNEX No. 3

LIST OF BIOMEDICAL EQUIPMENT BY SERVICE

Name of health facility:……………………………………………………………………………… Date:……………………………………

Own
Team brand Asset Code No.
No. Consulting room Name of the team Model Observations
Ye No
ah
1 Sterilizer Memmert 14 Lts. 1245-10 x
Yeny Enrríquez
Gastroenterology Sánchez / Clinic
2 Office flexible endoscope Olympus CHF-XP20 y/n x
gastroenterological
San Luis
3

4 medicine office Negatoscope

5
Digital pediatric
6
Pediatric office scale
7
Scale with
8 Gynecology office stadiometer
9
binocular
10 Laboratory
microscope

……………………………………………..

Medical Director, Chief Physician or

Person Responsible for Care

DNI N°……………………….

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care establishments of the Ministry of Health

ANNEX N° 04
LIST OF FURNITURE PER SERVICE
Name of health facility:……………………………………………………………………………… Date:……………………………………

Own
No. Consulting room Furniture Amount Observations
Ye No
ah
1 wooden desk 1
2 Swivel chair 1
Gastroenterology Office
3 Fixed chair 2
4 Medical examination 1
stretcher
4
medicine office
5

6
Pediatric office
7

8
Gynecology office
9

10 Laboratory

……………………………………………..

Medical Director, Chief Physician or

Person Responsible for Care

DNI N°……………………….

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX N° 05

SKETCH OR LOCATION MAP OF THE HEALTH ESTABLISHMENT

Name of health facility:………………………………………………………………………………

Date:……………………………………

IN IN

Establishment
of health

……………………………………………..

Medical Director, Chief Physician or

Person Responsible for Care

DNI N°……………………….

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX N° 06

DISTRIBUTION DISTRIBUTION DISTRIBUTION DISTRIBUTION DRAFT OF AREAS

AND SERVICES (METERS) OF THE
HEALTH FACILITY

Name of health facility:………………………………………………………………………………

Date:……………………………………

……………………………………………..

Medical Director, Chief

Physician or Person
Responsible for Care

DNI N°……………………….

Executive Directorate of People's Health – Directorate of Health Services Page 18

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX N° 07

MODEL OF AFFIDAVIT OF DATE OF START OF ACTIVITIES OF THE HEALTH

ESTABLISHMENT

SWORN DECLARATION

Those who subscribe, ......................................................................, Executive Director of the

Network…………………………………………………………..identified with DNI No.
and,
…………………………………..............., Medical Director, Chief Physician or person responsible for
care, of the health establishment ………… ……………………………………………… .................

WE DECLARE UNDER OATH THAT:

The aforementioned health establishment has begun its healthcare activities on the day
……………….of the month of ………………………………of………………

Lime,………………………………………………….

………………………..…………….. …………………………………………………….
Network Director Medical Director or Person Responsible for
Care
DNI N°………………………….. DNI N°……………………….

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX No. 8

MODEL AFFIDAVIT DECLARATION PROVIDING THAT THE HEALTH

ESTABLISHMENT HAS BASIC SERVICES

SWORN DECLARATION

Those who subscribe, ......................................................................, Executive Director of the

Network…………………………………………………………..identified with DNI No.
and,
…………………………………..............., Medical Director, Chief Physician or person responsible for
care, of the health establishment ………… ……………………………………………… .................

WE DECLARE UNDER OATH THAT:

The aforementioned health facility has electricity, water and drainage services installed and
operational.

Lime,………………………………………………….

………………………..…………….. …………………………………………………….
Network Director Medical Director or Person Responsible for
Care
DNI N°………………………….. DNI N°……………………….

Executive Directorate of People's Health – Directorate of Health Services Page 20

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care establishments of the Ministry of Health

ANNEX No. 9

MATRIX MODEL OF THE NUMBER OF MOBILE UNITS FOR LAND TRANSFER OF PATIENTS

TYPE OF
LAND AMBULANCE OPERATION
COMMUNICATIO
AL
MANUAL N
EESS NAME PATIENT YEAR OF
GRI MICRORED No. BRAND TYPE OF
TRANSPORT Manufacturi
D AMBULACY

CAR

VAN
STRETCH ng
TYPE I TYPE II TYPE III RADIO OR YE NO
COMMUNICATION AH
SYSTEM

1
2
3
4
5
6

……………………………………………..

Medical Director, Chief Physician or

Person Responsible for Care

DNI N°……………………….

Executive Directorate of People's Health – Directorate of Health Services Page 21

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care establishments of the Ministry of Health

ANNEX No. 10
SERVICE PORTFOLIO MODEL

SERVICES PORTFOLIO
MONTH YEAR
SERVICES PORTFOLIO (*) HUMAN RESOURCES (**)
OUTPATIENT CONSULTATION

ULTRASOUNDGRAPH

SOCIAL ASSISTANT
MICRORED

TECHNICAL
OBSTETRIST
HOURS OF ATTENTION
MEDICINE

CHEMICAL
NON-MEDICAL PROF.
OPHTHALMOLOGIST
HEALTH FACILITY

HOSPITALIZATION

SURGICAL CENTER

PHYSICIAN
ODONTOLOGY

DENTIST
LABORATORY

NURSE
GENERAL
EMERGENCY
NURSING TECH.

INTERNMENT

X-RAYS
GYNECOLOGY
PEDIATRICS

SURGERY
GENERAL

INTERNIST

BIRTH CARE
GRID……. Y c N Y c N Y c N Y c N Y c N Y c N Y c N

.
e e e e e e e
s s s s s s s

1 C.S.

2 C.S.

3 C.S.

S: SERUMS
C: Hired ……………………………………………..
N. Named
Medical Director, Chief Physician or
(*) Mark with (X) where appropriate. Person Responsible for Care
(**) Enter the number of professionals you have.
DNI N°……………………….

Executive Directorate of People's Health – Directorate of Health Services Page 22

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX No. 11

REFERENCE AND COUNTER REFERENCE FLOW MAP MODEL

- Prepare maps for outpatient consultation, diagnostic support, emergencies and emergencies.

……………………………………………..

Medical Director, Chief

Physician or Person
Responsible for Care

DNI N°……………………….

Executive Directorate of People's Health – Directorate of Health Services Page 23

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX N° 12

CHECKLIST OF DOCUMENTS THAT MAKE UP THE TECHNICAL FILE

HEALTH FACILITY
CATEGORY I-1 TO I-4
No. REQUIREME
NTS
Y NO
E
A
H

Letter signed by the Executive Director of the Network, addressed to the

1 General Director of DISA II LS, requesting a Directorial Resolution to
create a health establishment.
2 Copy of the document that certifies the legal status of the land.
3 Functional medical plan.
4 Human resources relationship (professional and non-professional)

5 Number and distribution of rooms by floor.

List of biomedical equipment by service, differentiating those owned from

6
those provided by third parties

List of furniture per service, differentiating those owned from those

7
provided by third parties.
Report on approval of architectural plans by the Executive Office of
8
Strategic Planning of DISA II LS.
9 Sketch or location map of the health facility.
Distribution sketch of areas and services of the establishment
10 health (metre)
List of biomedical equipment by service, differentiating those
11 own from those provided by third parties
List of furniture by service, differentiating those owned from those
12
provided by third parties
Civil defense security certificate, granted by INDECI or Municipality.
13
Statement sworn of date of start of activities of
14
the health facility.
Copies of electricity and water bills or sworn statement that the
15 health facility has electricity, water and drainage.
Matrix of the number of mobile units for land transfer of patients.
16

17 Services portfolio.

18 Map of reference and counter-reference flows.

Executive Directorate of People's Health – Directorate of Health Services Page 24

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

ANNEX N° 13

MINIMUM EQUIPMENT AND SUPPLIES BY UPS

SERVICE PRODUCING UNIT -

EQUIPMENT
UPS
Portable sciatica
Multi-use examination table
Rolling table for healing
Rolling metal IV pole
Two-section medical instrument display case
Mayo type rolling metal table
Rolling swivel stool
Two-step staircase
Rolling metal bucket holder with stainless steel bucket
Two-section rolling metal screen
Rolling secretion aspirator
Medical oxygen cylinder 3.4 m3, with accessories
Adult and child stethoscope
adult laryngoscope
Emergency care (Topical) Pediatric/neonatal laryngoscope
Pantoscope
Multiple nebulizer
Adult manual resuscitator
Pediatric/neonatal manual resuscitator
Adult aneroid blood pressure monitor
Instrumental healing set
Instrumental set for small surgical interventions
Instrumental set for gynecological examination
Stretcher with rolling frame (patient transfer)
Mechanical standing scale with stadiometer
Wheelchair
Cardiopulmonary resuscitation case
stop car
Multi-purpose examination table
Desk table with drawers
Desk with drawers
Chairs
Metal scale with stadiometer
Pediatric tabletop mechanical scale
Outpatient consultation - Pediatric aneroid blood pressure monitor
Child pediatric stethoscope
Metal screen of one body
Metal display case for single body material
1 field negatoscope
Pediatric pantoscope

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

MINIMUM EQUIPMENT AND SUPPLIES PER UPS (continued)

SERVICE PRODUCING UNIT -

EQUIPMENT
UPS
Gynecological table
Two-step staircase
Desk
3 chairs
Instrument display case
Adult scale with stadiometer
Blood pressure monitor with cuff for adults
Outpatient consultation - gauze drum
Woman Stethoscope with bell and diaphragm
Two-section metal screen
Reflex hammer
Metal waste bin with lid
Swivel stool
Centimeter or inextensible tape measure
Fetoscope
Healing table
Gooseneck lamp
Bucket with its bucket holder
Paper bin
Specula
Ring forceps (Foester)
IUD insertion kit
Bozzeman Vaginal Cleaning Tweezers
Hysterometer
Mayo curved scissors 20 cm.
Pozzi bullet thrower
Adult oral thermometer
Gestogram
Object holder clamp, medium
26 x 14 cm waist bag
Metallic steel bucket with lid 26x22x6 cm.
Women's Office Metal box for instruments 33x13x9
18 x 18 metal drum
30 cm curved Mayo scissors.
Sterile gloves 6½, 7, 7½, 8
Wide mouth bottle (Papanicolaou slides)
Antiseptic solution (Savlón)
Distilled water
Iodized alcohol
Iodized benzine
Liquid soap
0.9% sodium chloride solution
tincture of iodine
liquid Vaseline
Tapes to detect albumin in urine
pH litmus tape
Poor language

Executive Directorate of People's Health – Directorate of Health Services Page 26

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

MINIMUM EQUIPMENT AND SUPPLIES PER UPS (continued)

SERVICE PRODUCING UNIT -
EQUIPMENT
UPS
Wooden Ayre Spatula
cotton swabs
Kraft paper
Sterile cotton
Sterile gauze
Anti-allergy tape
Umbilical cord ligation
1 cent clips
Wax pencils
bleach solution
Toothbrushes and dental mold for education
Simplified perinatal clinical history
Woman's medical history
perinatal card
Women's Clinic (continued) Recipe books
HIS-MIS records
Pap Smear Records
Registration book for women of childbearing age (single book)
Pregnant women registration book (single book)
Appointment notebook
Appointment card
Educational flipcharts and posters
Pregnant woman feeding card
1.5 x 1 m plastic screeds.
Exam gowns
Hand towel
Aprons
Stretcher for medical examination
Two-step staircase
Two-section metal screen
Desk table with drawers
Chairs
2-field negatoscope
Adult - Pediatric Aneroid Blood Pressure Monitor
Adult - Pediatric Stethoscope
Adult/child medicine outpatient
Two-section display case for medical supplies
consultation
Pantoscope
Recipe books
Lower tongues
Flashlight for medical examination
Reflex hammer
Paper towel
Liquid soap
Amalgamator
Ultrasonic descaler
Electric autoclave 15 lit.
dentistry office Complete dental unit
Instrumental set for extraction
Dental diagnostic instrument set
Dental surgery instrument set

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Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

MINIMUM EQUIPMENT AND SUPPLIES PER UPS (continued)

SERVICE PRODUCING UNIT -

EQUIPMENT
UPS
Modular table
Desk with drawers
Dental office (continued) Chairs
halogen light lamp
1 field negatoscope
Dental display case for material, two sections
Gynecological table
Gooseneck lamp
Healing table
Two-step staircase
Mayo type rolling metal table
Tabletop secretion aspirator
Rolling swivel stool
Portable sciatica
Rolling metal bucket holder with stainless steel bucket
Rolling metal IV pole
Radiant heat crib for newborn care
Pediatric tabletop mechanical scale
Room heating stove
Medical oxygen cylinder 3.4 m3, with accessories
Pediatric/neonatal manual resuscitator
Preparation room, dilation, birth Neonatal laryngoscope
care and newborn care adult stethoscope
neonatal stethoscope
Pediatric aneroid blood pressure monitor
Instrumental set for childbirth care
Episiotomy instrument set
Instrumental set for cervical examination
Instrumental set for puerperal curettage
Rolling acrylic crib for newborns
Two-section instrument display case
Transport incubator
Pulse oximeter, portable
Rolling metal crib
Secretion aspirator
Tub
Standard incubator
Neonatal laryngoscope

Executive Directorate of People's Health – Directorate of Health Services Page 28

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

MINIMUM EQUIPMENT AND SUPPLIES PER UPS (continued)

SERVICE PRODUCING UNIT -

EQUIPMENT
UPS
Operating table
anesthesia machine
Rolling secretion aspirator
Ceiling sciatica
Rolling IV pole
Anesthesia table
Instrument display case
May type curved table
Two-body negatoscope
Oxygen cylinder
Rolling swivel stool
Rolling bucket pot with bucket
Operations room
Lavatory holder with metal sinks
Two-step staircase
5 parameter monitor
portable defibrillator
Set of minor surgery interventions
Curettage set
Caesarean section set
laparotomy set
Laryngoscope
Adult manual resuscitator
Neonatal resuscitator - pediatric
Standard binocular microscope
Universal tube centrifuge
Microhematocrit centrifuge
Clinical pathology (laboratory)
Differential blood cell counter
Refrigerator, with thermometer
10 - 15 Lit water bath.
clinical bed
Rolling IV pole
Paper bin
Observation/rest environment Two-section metal screen
Two-step staircase
Flat
Parrot

Executive Directorate of People's Health – Directorate of Health Services Page 29

Administrative Directive: Preparation of the technical file to request Directorial Resolution for the creation of first level care
establishments of the Ministry of Health

MINIMUM EQUIPMENT AND SUPPLIES PER UPS (continued)

PRODUCING UNIT OF
SERVICE - UPS EQUIPMENT

Desk
High cabinet with door
Shelf with slotted angle
Pharmacy / First aid kit
Swivel chair
Computer with printer
Three-step staircase
Refrigerator
Freezer
Vaccine holder thermos
Cold chain
Microphone and speaker
Work table
Flipchart support
Transport stretcher
Ambulance
8 KVA generator set
Others
radio communications equipment
Elevated tank
Electric pump or hydropneumatic equipment

The equipment and personnel requirements are established according to the category and/or type of service
offered, which must be correlated with the technical standards detailed below and others that, due to the
nature of the service to be offered, are approved. at the central level: RM N° 588-2005/MINSA: “List of basic
biomedical equipment for health establishments”; RM N° 970 – 2005/MINSA: “Technical health standard for
architecture, equipment and furniture projects for primary care health facilities”; “Standard of infrastructure
and equipment of the first level of care”

Executive Directorate of People's Health – Directorate of Health Services Page 30