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1 Facility Name
2 Municipality 3 Province
4 Type of Facility:
Health Center/Clinic Specialized Maternity Clinic/Lying-in
Health Center/Clinic + Birthing Home Other (specify):
5 EMR 6 ERM Use 6 EMR inclusion
iClinicSys SHINE OS+ RxBox Others:
Seg-RHIS Other: For those with EMR answer all except Q13 & Q14; those
eHatid LGU None without EMR answer only Q13 to Q17.
7 With MOA and SLA Yes 8 Using Approved Informed Yes
No Consent Form Template No
9 Implementation 10 Encoding
Parallel with paper-based documentation Point of care documentation
Full Electronic Back encoding
11 Modules Implemented 12 Report System-generated
Full EMR with at least the following modules: consultation, Generatio Paper Record
maternal, child health, family planning, TB n
Selected modules only (enumerate)

For those without EMR, answer only questions 13 to 17.

13 Preferred EMR 14 Status of engagement with the EMR Provider
iClinicSys SHINE OS+ (please include dates)
Seg-RHIS Other:
eHatid LGU


15 Internet DSL 16 Large Server 17 Wired Network
Connectivity Mobile Local CPU Server Network in Wifi Network
Cable Server Laptop Server the RHU
None None
18 Number of machines (desktop 19 Number of functional machines
and laptops) (desktop and laptops)
20 Number of HSPs (RHU + 21 Number of HSPs 22 Number of HSPs
satellite facilities) trained on the EMR actively using the EMR
23 EMR Provider Support Rating Poor 1 2 3 4 5 6 7 8 9 10 Excellent
24 EMR Provider Support

1. Facility Name Write the name of the full name of the facility.
2. Municipality Write the municipality where the facility is situated.
3. Province Write the province where the facility is situated.
4. Type of Facility Tick the type of facility being assessed.
5. EMR Identify the electronic medical record being used by the facility.
All the listed EMRs are approved and compliant to the DOH-
PhilHealth requirements. Please specify if the EMR is not listed.
6. EMR inclusion Identify other system/device included in the EMR package
implementation. RxBox is the telemedicine device that captures
vital signs and monitors pregnant women during labor. SPASMS
on the other hand is an SMS reminder service of WAH.
7. With Memorandum According to the Philhealth Advisory 2016-0040: PCB Providers
shall ensure that there are appropriate Memorandum of
Agreements (MOAs) and Service Level Agreements (SLAs)
made between their Management and EMR Providers.
8. Using Approved Informed According to the Philhealth Advisory 2016-0040: In compliance
Consent Form Template with RA 10173 or the Data Privacy Act of 2012, PCB Providers
shall be required to provide and ask the patients to review and
sign an Informed Consent Form (Annex A - Approved Informed
Consent Form Template), and make sure that the patients
understand its contents prior to signing. Signed Informed
Consent Forms shall be safely kept and made available by the
PCB Providers for legal or audit purposes.
9. Implementation Identify how the EMR is being implemented in the facility. The
first option is a parallel implementation of the EMR and the
paper-based documentation. Choose the second option if the
facility document all ITR and service delivery using the EMR.
10. Encoding Identify how the facility documents services. Point of care
documentation is when a HSP records data while providing
services. Back encoding is when a HSP records data on paper
and s/he or an encoder will encode the details of the services
provider in a different time.
11. Modules Implemented Tick the first option if the full EMR is implemented in the facility;
fully utilizing the consultation, maternal and child, family planning
and TB modules. Tick the second option and enumerate if only
selected modules of the EMR is being utilized.
12. Report Generation Identify how the report is being generated: system-generated
using the EMR or still base on the paper record.
13. Preferred EMR If the facility doesnt have EMR yet, identify the preferred EMR.
14. Status of engagement with If the facility has already contacted an EMR provide, provide
the EMR Provider information on the engagement. Identify the status if they are
already scheduled for initial assessment, training or for roll-out.
15. Internet Connectivity Identify the internet connection of the facility. Choose DSL if the
internet is coming from a phone line, mobile if from a mobile
broadband stick or mobile router, and cable if it is coming from a
cable (TV) line.
16. Local Server Identify the local server being used by the facility. Tick large
server for industry type database server, CPU server for the
regular CPU customized as a server or laptop server if the
facility is using a laptop customized as the server.
17. Network in the RHU Identify how the machines inside the facility is connected to the
server. Tick wired if the facility is using LAN or local area
network or via wifi network if they connect using a wifi router (do
not necessarily mean that they have internet).
18. Number of machines Identify the number of laptops and desktop computers in the
(desktop and laptops) facility.
19. Number of functional Identify the number of laptops and desktop computers that is
machines (desktop and functioning and it is being used for the EMR.
20. Number of HSPs (RHU + Identify the number of HSPs in the main facility as well as its
satellite facilities) satellite clinics.
21. Number of HSPs trained on Identify the number of HSPs in the facility trained in using the
the EMR EMR.
22. Number of HSPs actively Identify the number of HSPs in the facility actively using the
using the EMR EMR. Those who have encoded/updated a record for the past
23. EMR Provider Support Rate the support given by the EMR provider (training to
Rating implementation).
24. EMR Provider Support Write the feedback of the facility on the support extended by the
Feedback EMR provider.