Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012) Page 1

NAME__________________________________________ Yr. & Section _______________

Name of Hospital _______________________________________________________________

Address ______________________________________________________________________

Date of Internship ______________________________________________________________

SURVEY TOOL FOR HOSPITAL PHARMACY

Dear Students:

You are requested to fill up completely this evaluation tool. There is no right or wrong answer.

Your honest evaluation is important to have an accurate conclusion. Thank you for your time.

Pharmacy Internship Committee

DIRECTIONS: Using the scale below, please encircle the code opposite each item to rate the

extent by which each item is practiced in the hospital pharmacy.

4 = Great Extent (GE) 2 = Little Extent

3 = Moderate Extent (ME) 1 = Negligible or Not At All

I. General Provisions:

1. The hospital pharmacy conducts training of pharmacy students

affiliated with the hospital that meets the requirements of the

DOH NCATS/RCATS. (AO 70-A s. 1989)

4 3 2 1

2. There is a well-organized Pharmacy Service conducted in

accordance with ethical and professional practices and properly

licensed by the BFAD in the issuance of an LTO in accordance

with the Food, Drugs, Devices and Cosmetics Act ([FDDCA] RA

3720 as amended) and the Bureau of Licensing in accordance

with the Hospital Licensure Act (RA 4226) and the Dangerous

Drugs Act.

4 3 2 1

3. The hospital pharmacy provides orientation to the interns prior to

the start of the internship.

4 3 2 1

4. There is a registered pharmacist who supervises the intern during

the internship.

4 3 2 1

5. The physical presence of a licensed pharmacist is ensured

especially when the pharmacy is open for service and/or the

pharmacy renders 24 hours service.

4 3 2 1

6. There is a PTC that provides rational drug therapy.

7. The hospital pharmacy ensures continuous supply of drugs and

medicines of the highest standards to patients by maintaining an

adequate quantity of stocks in the hospital pharmacy.

8. The hospital pharmacy conducts the preparation and compounding

of bulk sterile and non sterile pharmaceuticals approved by PTC.

Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012) Page 2

9. Provides IV admixture program.

10. There are adequate provisions for equipment, chemicals for

compounding and dispensing (standard laboratory equipment,

laminar flowhood, prescription balance, pill tile, mortar and

pestle, etc.

4 3 2 1

11. There are adequate provisions for reference books and record

books duly registered with BFAD (PNDF, USP/NF RPS,

Goodman and Gilman Pharmacological Basis of Therapeutics,

R.A. 6675, R.A. 5921, R.A. 8203, Prescription Book and

Dangerous Drug Book,

Exempt Preparation and Poison Book)

4 3 2 1

12. The hospital pharmacy conducts the screening, filling and proper

dispensing of drugs in accordance with the laws, rules and

regulations pertinent thereto. (RA Nos. 5921, 3720, 6425, 6675)

13. Maintains records, files and submit reports on dangerous drugs

and other pharmaceuticals in compliance with pertinent laws,

rules and regulations.

14. The hospital pharmacy controls the labeling and packaging of

drugs that complies with standards and legal requirements.

15. There is enough space for a pharmacist to observe and supervise

all interns assigned in the pharmacy department.

4 3 2 1

16. There is a Policy and Procedure Manual on training/internship

which is implemented consistently.

4 3 2 1

17. The physical-set up of the pharmacy department is in accordance

to the acceptable standard.

4 3 2 1

18. The hospital pharmacy serves as Drug Information Center to all

hospital personnel, students and patients.

4 3 2 1

19. The hospital pharmacy is properly lighted, well-ventilated and has

an area of not less than 15 sq. m. with concrete tile or wooden

flooring.

4 3 2 1

20. There is a unit dose drug distribution system used in the hospital.

21. The arrangement of furniture allows enough space for movement

and work.

4 3 2 1

22. The pharmacy department provides a suitable place for adequate

storage of drugs and biological products specified on the labels.

4 3 2 1

23. The appearance of the pharmacy department is aesthetically neat

and orderly.

4 3 2 1

24. There are clear provisions in the preparation and signing of the

Requisition Issue Vouchers (RIVs) with complete specifications

of drugs indicating the quantity and cost based on the official

Price Schedule for actual procurement.

4 3 2 1

25. There are clear provisions for the invoices indicating the lot

number/batch number of the manufacture’s stock pursuant to

BFAD, file of prescription filled consecutively numbered, dry

4 3 2 1

Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012) Page 3

seal or rubber stamp, red or white label indicating the number and address of the hospital.

26. There is a summative evaluation of the internship activities and

the student performance upon completion of the required number

of hours by the intern.

4 3 2 1

27. A drug inventory system is maintained by the hospital pharmacy

adopting the FIFO method in dispensing and distributing drug

stocks.

4 3 2 1

28. The institution develops a pharmaceutical research. 4 3 2 1

29. There is a provision for continuing education for pharmacy staff

and support personnel

30. A pharmacist on duty always wears the prescribe uniform 4 3 2 1

II. Pharmacist/Personnel Attitudes and Competencies

1. Plans and conceptualize internship activities 4 3 2 1

2. Meets the needs of the intern 4 3 2 1

4. Is willing to work long in a traditional hours in order to assist

interns.

4 3 2 1

4. Delegates the task fairly 4 3 2 1

5. Guides the interns in their work of:

a. compounding, labeling and packing 4 3 2 1

b. TPN preparation 4 3 2 1

c. preparing stock solution 4 3 2 1

d. handling of ethical and dangerous drugs 4 3 2 1

e. pricing the prescription 4 3 2 1

f. recording of prescription 4 3 2 1

g. dispensing of drugs 4 3 2 1

h. disseminating drug information 4 3 2 1

i. preparing inventory of drugs and other resources of drugstore. 4 3 2 1

6. Monitors and evaluates the activities and performance of the

interns professionally and fairly

4 3 2 1

7. Is willing to share his/her management and professional

experience/training.

4 3 2 1

8. Provides or suggests solutions to problems 4 3 2 1

9. Inspires the interns to work with commitment. 4 3 2 1

10. Encourages the interns to be respectable and trustworthy. 4 3 2 1

11. Performs consistently the tasks (student related activity) within the

Drugstore.

4 3 2 1

12. Adapts easily to constant change of people, places and things. 4 3 2 1

13. Treats all interns fairly and honestly. 4 3 2 1

14. Is courteous and tactful to interns. 4 3 2 1

15. Relates well to staff and interns 4 3 2 1

Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012) Page 4

III. Facilities

1. Sufficient facilities in good condition are available. 4 3 2 1

2. Up-to-date facilities are available 4 3 2 1

3. The physical and material resources are arranged orderly. 4 3 2 1

4. There is flexibility for the physical and material resources. 4 3 2 1

5. The physical facilities and compounding areas are clean. 4 3 2 1

6. The interior design of the hospital pharmacy is simple and attractive. 4 3 2 1

IV. Location

1. The site is convenient to patients 4 3 2 1

2. The hospital pharmacy is accessible to public transportation. 4 3 2 1

3. The hospital pharmacy has enough parking space 4 3 2 1

4. The hospital pharmacy has adequate provision for expansion. 4 3 2 1

5. The hospital pharmacy has enough security measures for safety i.e

adequate lights, presence of security guard

4 3 2 1

V. Patient Service

1. The hospital pharmacist has the competencies required. 4 3 2 1

2. The hospital pharmacist renders prompt and quality service 4 3 2 1

3. The hospital pharmacists are courteous and approachable. 4 3 2 1

4. The frontline staff is friendly. 4 3 2 1

5. The hospital pharmacist communicates clearly with the patients

specially on dosing regimen and how the drug should be taken

4 3 2 1

6. The hospital pharmacists attend to patients’ comments and

feedbacks.

4 3 2 1

Pls. rate the hospital pharmacy as a whole from 1-5 with 5 as the highest point. _________.

Would you personally recommend this hospital pharmacy as a training site for Pharmacy

students in Hospital Pharmacy? A. Yes B. No

Remarks:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________