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Checklist for Monitoring CHC/FRU

Name of the State :- _________________________________________________________Name of the District :- _________________________________________________________ Name of the Block :- _________________________________________________________Name of the CHC/FRU :- _________________________________________________________Address :- _________________________________________________________Population coveredby CHC/FRU (in numbers) :- _________________________________________________________Total number of beds :- _________________________________________________________Name & Designation of

the Head of the institute :- _________________________________________________________Contact Details :- Office :- ___________________ Mobile :- ___________________

Email :- _______________________________________________ Date of Visit :- ________________ Name & Signature of theperson collecting information:- __________________________________________________________

I ManpowerPersonnel IPHS norms Sanctioned In Position Remarks

Clinical Manpower 1 General Surgeon 12 Physician 13 Obstetrician/Gynecologist 14 Pediatrics 15 Anaesthetist 16 Public Health Programme Manager 1

7 Eye Surgeon 1Support Manpower 1 Nursing Staff 7+22 Public Health Nurse 13 ANM 14 Staff Nurse 75 Nurse/Midwife6 Dresser 17 Pharmacist / Compounder 18 Lab. Technician 19 Radiographer 1

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II Training Status (Kindly procure a copy of trained personnel)

Name of the Trained Person Designation Name of theTraining Received Date

1

2

3

4

5

6

7

8

910

11

12

13

14

15

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III Feedback of Trained Personnel

Name of Trained Personnel :-

Name & Date of the last training received :-Questions Yes/No Remarks

1 Was the purpose/objective of taking the training fulfilled?2 Was the duration of the training was sufficient?

3 Was the course content sufficient?

4 What did you like most about the training that you received?(put mark) Content Training Methodology Used Training skills Practical demonstration Training Environment Field Visits Accommodation & Food

5 Any component(from the options above)of training that

you are not satisfied with?

Kindly state in detail

6 Any training materials given to you?7 Are those materials available in the CHC?

8 Do you feel the training that you received is beneficial to youin service delivery?

9 If No, Give the Reason (List out the problems)

10 Are you unable to utilize the skills learnt during the trainingat work place11 If Yes, Give the Reasons (put mark)12 Inadequate training

Lack of Infrastructure Lack of Drugs and Equipments Lack of supporting staff

Administrative Problems13 Any other training that you feel will be beneficial for your work? ( List the name of the trainings)

14 Any suggestions regarding training

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IV Facility Monitoring for CHC/FRUA Infrastructure

2 QuestionsYes/No/

Functional (mark F)/Non-Functional

(mark NF)

Remarks

Is a designated Government building available for theCHC?Where is this CHC located?

Within village locality

Far from village locality

If far from locality (specify in km)3 Is pharmacy available?

4 Are OPD rooms / cubicles available?

5 Availability of facilities for out-patient department inGynecology/ Obstetric Adequate working space

Privacy during examination

Facility for counselling

Facility for Sterilizing instruments

Male specialist

Female specialist

6 Emergency Room / Casualty available?

7 Is family Welfare Clinic available?

8 Waiting room for patients available?

9 Separate wards for males and females available?

10 Fully furnished and equipped Labour room(as per the annexure I)available?11 If Labour room is present, are deliveries carried out inthe Labour room 24x7?

12 If Yes, Availability of New born care facilities New Born table

Pediatrics Ambu Bag & Mask

Radiant warmer / 200 watt lamp

Mucus sucker / Suction machine

Oxygen hood & Cylinder

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13 If deliveries not being conducted 24x7, then what arethe reasons for the same? Shortage of staff

Staff not staying at PHC

Poor condition of the Labour room

No power supply in the Labour room

Any other specify

14 Are separate areas for septic and aseptic deliveriesavailable?15 Is newborn stabilization unit available?

16 Is operation theatre available?

17 If operation theatre is present, are surgeries carriedout in the operation theatre?

18 Is Operation Theatre used for Obstetric/Gynecological purpose?

19If operation theatre is present, but surgeries are notbeing conducted there, then what are the reasons for the same?

Non-availability of Doctors/Anaesthetist/Staff Lack of equipment/poor physical state of the

operation theatre No power supply in the operation theatre

20 Any other reason (specify)

21 Is Blood Storage Unit available?

22 Is the CHC having linkage with district blood bank?

23 Is regular blood supply available?24 Ancillary Rooms - Nurses rest room available?

25 Cold Chain facilities available

Walk-in coolers

Walk-in freezers available

Ice lined freezers

Deep freezers

Refrigerators

26 Are laboratory facilities available?

27 Is proper water supply available?

28 Is regular power supply available?

29 Is power back up available?

30 Are separate toilets for males and females availableand functional?31 Is store room available?

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32 Is kitchen available and operational in the CHC?

33 Does the CHC provide diet to the patient?

34 Are colour coded containers for waste disposalavailable?35 Is bio-medical waste pit available?

36 Is there an incinerator?

37 Laundry facility available?

38 Is Telephone facility available and functional?

39 Computer available?

40 Is transport facility for movement of staff availableand functional?

41 Is residential facility for the staff available with allamenities available? General Surgeon

Physician

Obstetrician / Gynecologist

Pediatrics

Anaesthetist

General Duty Medical Officer

Public Health Nurse

ANM

Staff Nurse

Nurse/Midwife

Pharmacist/Compounder

Lab. Technician

Radiographer

OT Attendant

Ambulance driver

42 Are essential drugs available?(as per Annexure II enclosed)

43 Is transport (Ambulance) for referral available andfunctional?

44 Name of the nearest referral centre (Mention the distance)

V Health Services Yes / No Remarks

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Following Specialist services available Medicine Surgery OBG Pediatrics Emergency services (24 x7)

Ante-natal Clinics providing complete ANC services Post-natal Clinics Immunization Sessions, If Yes

Are the Immunization services as per Govt. schedule

24 hour Delivery Services( including normal and assisted deliveries)

Managing Labour using Partograph(Ask to show for last delivery conducted)

Minimum 48 hours of stay post delivery Emergency Obstetric Care including surgical interventions

like Caesarean Sections and other medical interventions Is the facility for referral of complicated cases of

Pregnancy/Delivery available 24X7 at CHC? Are the facilities under Janani Suraksha Yojana provided? New-born care Emergency care of sick children Full range of family planning services including

Laproscopic Services Safe abortion services Treatment of STI / RTI Essential Laboratory Services Blood storage facility Availability of counselling facility on HIV/AIDS/STD etc.

Is it a Voluntary Council and Testing Centre (VCTC)?

VI Investigation ServicesA Laboratory Services7

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Name of the Test Yes/No Remarks1 Hematology

Hb Total Leukocyte count Differential Leukocyte count Absolute Eosinophils count Reticulocyte count Total RBC count E.S.R Peripheral Blood Smear Malaria/Filaria Parasite Platelet Cell volume Blood grouping Rh typing Blood cross matching

2 Urine Analysis Urine for Albumin

Sugar Deposits Bile salts Bile pigments Acetone Specific gravity Reaction (pH)

3 Stool Analysis Stool for Ovacyst Hanging drop for V. Cholera Occult blood Sputum cytology

B Radiological Services X Ray services USG services ECG services

Annexure I8

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CHC/FRU

List of Furnitures in Labour Room

Sr.No Item Yes/No Remarks1 Examination Table2 Delivery Table3 Footstep

4 Bed Side Screen5 Stool for patients6 Arm board for adult & child7 Saline stand8 Wheel chair 9 Stretcher on trolley

10 Oxygen trolley11 Height measuring stand12 Iron bed13 Bed side locker 14 Dressing trolley15 Mayo trolley16 Instrument cabinet17 Instrument trolley18 Bucket19 Attendant stool20 Instrument tray21 Chair 22 Wooden table23 Almirah24 Swab rack

25 Mattress26 Pilow27 Waiting bench for patients / attendants28 Medicine cabinet29 Side rail30 Rack 31 Bed side attendant chair

List of Equipments and consumables in Labour Room

Sr.No. Item Yes/No Remarks1 Basin 825 ml., (Stainless Steel)

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2 Basin deep (capacity 6litre)3 Tray instrument/Dressing with cover4 Flashlight5 Torch (ordinary6 Dressing Drum . with cover7 Hemoglobinometer set Sahli type8 Weighing Scale, Adult9 Weighing Scale, Infant

10 Weighing Scale, (baby)11 Tissue Forceps12 Sterilizer13 Surgical Scissors straight14 Sims Uterine Depressor/Retractor15 Measuring Jug16 Surgeons Scrubbing Brush with white

NylonBristles

17 Sphygmomanometer18 Kellys hemostat Forceps straight

19 Vulsellum Uterine Forceps curved20 Cuscos/Graves Speculum vaginal bi-valve

21 Sims Speculum vaginal double ended22 Uterine Sound23 Cheatles Forcep24 Vaccine Carrier25 Ice pack box26 Sponge holder27 Plain Forceps28 Suture needle straight & curved29 Clinical Thermometer oral & rectal30 Room Heater/Cooler for immunization

clinic with electrical fittings31 Foetoscope32 Dressing Forceps (spring type33 Artery Forceps, straight,34 Cord cutting Scissors35 Stethoscope36 HUB Cutter37 Ambu Bag38 Measuring Tape39 I/V Stand40 Tracking Bag and Tickler Box

(Immunization)

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Annexure II

Emergency Obstetric Care Drugs Kit for CHC/ FRU

Sr No Items Yes/No Remarks

1 Halothane BP2 Atropine Injection3 Thiopentone Injection4 Bupivacaine Injection5 Lignocaine Injection6 Pentazocine Injection7 Diazepam Injection8 Dexmethsone Injection9 Promethazine Injection

10 Nifedipine Capsules

11 Digoxin Tablets12 Frusemide Tablets & Inj13 Ampicillin Injection14 Gentamycin Injection15 Amoxycillin Capsules16 Norfloxacin Tablets17 Theophylline IP18 Benzathine Penicillin Injection19 Ergometrine Tablets20 Magnesium Sulphate Injection21 Ketamine Injection22 Adrenaline Injection

Drug Kit For Sick New Born & Child Care

SrNo Items

Yes/No Remarks

1 Diazepam Inj.2 Inj. Cefotaxime3 Inj. Cloxacillin

4Dexamethasone Sodium Phosphateinj.

5 Adrenaline inj6 Inj Phenytoin7 Inj. Gentamycin8 Inj Ciprofloxacin

9Salbutamol nebusolsolution(to be used with nebuliser)

10 Inj. Lasix11 Inj. Calcium Gluconate12 Inj. Dopamine13 Inj Vit. K3

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