u i uh'c. ,do/3a51 /rrff' · date ofvisit - data of previous 'tontn from facility ....
TRANSCRIPT
Interval ,0
Postpartum D Post Abortion Z'.)
Supportive Supervision Checklist
uH'C.
r;-:-Name of the supervisor
C4: Facility Name U Block District
C7 : Date of visit -
Data of previous 'tontn from facility
D1 Number of deliveries in facility
~ft-<. u 3: Level of supervisor - Block/ Dist rict/ State /Nationa l / Oth er
CS: Facility Type - SC/ Non 24 *7 PHC /24*7 PHC/Non- FRU CHC/FRU • . CHC/SDH/DH/AREA HOSP/other I ,Do/3A51 .f?/rRff' C6: Fac,lity Level - Ll/ L2/ L3
CS: Name of Facility in-charge/nodal officer C9: Designat ion of In-charge
02 Number of new-borns
immu nized before discharge 0 El.5: Mifepristone + Misoprostol (MMA) 'I- E3.5: Sterile cord cutting equipment / E8.3: Refrigerator ~
E Drugs/supplies availability (If possible, verify physically)
El : Reproductive Health _E3: New Born Health E7. Antibiotics /
El.1: IUCD 375, 38~ E3 .1: lnj. Vit Kl(l mg/ml) E.7 .1 Antibiotics as per RMNCH +A SXSfY Matrix ( Amoxycli llin, Ampicillin, Ampicillin, Gentamicin, Metronidazole, Trimethoprim &Su lpha methoxazole, ' Cef rtiaxone (oral/lM/IV as applicable)
y
El.2: 0CP w E3.2: Mucus Extractor ES: Other essential supplies °1 &equipments(check
functionality & utilization)
D
/
El.3: ECP E3.3: Bag and mask f- E8.1 Weighing Machine O~ (240 ml) w it h both pre & t erm mask (size 0,1),. Q/
...,,.-El.4: Condoms J.-....-E3.4: Clean linen/towels for receiving new boi/ E8.2: Hub cutter with needle destroyer 0" ~
Total Deliveries ~ Normal I
Assisted Vaginal Delivery
C-section
Referred ou t cases
Live births
El.6: MVA Kit/EVA :x... E3.6: Designated Newborn Care Corner/ , f( · l l E8.4: RTI/STI Kit I).{ 03 IPD load I 'I-- i E2: Maternal Health E3.7: Functional Radiant Warmer / UV ~ E8.5: Bleaching Powder ty
E2.l: lnj. 0xytocin (check whether stored E8.6: Oxygen Cyli nder functional I04 OPDload l/~C ] 9-_ E4: Child Health ~
in cold box/refrigerator) / -E2.2: Tab Misoprostol Cf E4.1 ORS V E8.7: BP apparatus with stethoscope 9-"'D5 IUCD inserted i n facility
--· 1 E2.3: Anti hypertensive (alpha fl--, -F4.2: Zinc (10mg & 20 mg) E8.8: Thermometer t!---methyldopa/Labetalol or Nifedipine) ~
D6 Sterilization done
Female interval steril ization }(.
Female postpartum steril ization /" Male sterilization 'I-.
D7 No. of clients received CAC services D8 No of women received IFA tab D9 No. of ANC clients with high
risk conditions 83D10HR d_ep~oyed/posted in Labor Room
E2.4: lnj. Magnesium Sulfate
~ E4.3: Syp Salbutamol/Salbutamol Nebulizing Solution
\l E8.9: PPI UCO Forceps 0,.-/
v E2.5: lnj. Tetanus Toxoid 1Q/ E4.4: Tablet Albendazole ~ E8.10: Fetoscope/ Doppler rn--E2.6: Sterile pads ~v E.5: Adolescent Health E8.11: Autoclave/Boiler a----E2.7: IFA Tablet
E2.8: Pregnancy Test Kit (only at sub-tt-- ES.l: Dicyclomine
D l.-£5.2: Weekly Iron folic acid supplementation
g.--, E8.12: Running water
E8.13: Soap
~ g_...-----
centres and with ASHAs) \....-"" tablets
E2 .9: Functional Blood Bank/blood storage units t E 5.3 Tablet Albendazole
./
.--E8.14: Color coded bins and bags~ u.-E2.10: Haemoglobinometer 0,,- E6: Vaccines E8.15: Electricity back-up u----·
" E2.ll: Urine albumin kit lU/ E6.l: BCG cg..- E8.16: Toilett ear LR) D E 2.12: Blood grouping typing g_ E6.2: 0 PV 0-- ~
E 2.13:HIV screen ing 6l_ EG.3: Hep B g.. E 2.14:Hepatitis B screening [J. E6.4: DPT ,(L.. E8.17: Cold box, ILR, Deep freezer D E2 .15: Partograph
E2.16: Protocols displayed in LR --·
;;... ~
E.6.5: Measles
E.6.6: Syrup Vit. A
Q__.. P'\
present for vaccine storage as per requirement V
E2.l7: IV Fluids - ·, E 2.18 lni Dexam@rhasone
,\fr
m E.6.7: Pentavalent vaccin~ (in relevant states) E.6.8 JE Vaccine /where re :evantl
B- E 8.18 MCP cards
~ ~ D -
-I
MO
ANM/Sta ff nurse
Post I Trained in I ed SBA/ I PPIUCD I NSSK
BEmOC
3.~,,.,, t PJ+rv
1 Fl. Ante Natal Care
Fl.l Blood Pressure Measured during ANC visits
Response
0/'fes D No D NA
Fl.2 Ha emoglobin measured during ANC visits Q_,Xes D No D NA
FL.3 Blood Glucose measured during ANC visits Q__yes D No D NA
Fl.4 Urine Albumin measured during ANC visits lP--"1es D No D NA
Fl.5 Appropriate management/referra l of high risk clients (identified on the basis of High BP/ Blood sugar/ Haemoglobin} '13-Yes D No D NA
Fl.6 Family Planning Counsel ling happening during ANC visit s -8-Yes D No D NA
F2. Intra F2.1 Fetal Heart Rate {FHR} recorded at t he time of admission 0-----Yes D No partum and Immediate post-partum practices
F2.2
F2.3
F2.4
f2.S
Mother's temperature and BP recorded at the t ime of admission
Partograph used to monitor progress of labor
Antenatal corticosteroids used for preterm labour
M agnesium Sulphate used to manage severe Pre-eclampsia and Ecla mpsia cases
Cv- Yes
~ Yes
~ Yes D
QI.. Yes
D 0
No
0
No No r:g..---ffA
No
F2.6 Uterotonic (Oxytocin or Misoprosto l} given to mother immediately after birth of baby \ ~ Yes 0 No
F3. Essentia l F3.1 Newborn ca re corner adequately equipped (bag-and-mask, rad iant warmer, mucous extractor, shoulder ro ll, thermometer, clock, Oxygen source) I 0 Yes 0 No new born care (ENBC) and Newborn Resuscitation (NBR)
F3.2
F3.3
F3.4
F3.S
F3.6
Early initiation of breastfeeding practices
Practice of skin to skin contact being promoted
Babies dried with clean and sterile sheets/towels just after delivery
Provider aware about the steps of new-born resuscitation (Positioning, suctioning, stimulation, repositioning , PPV using Ambu bag)
New-barns given BCG,OPV, Hep-B within 24 hours of birth /
I {
l I
-" fl/ r , 0 0
0
0 0
Yes
Yes
Yes
Yes
Yes
0 0
0
0 0
No No
No
No No
F4. Family F4.1 Family planning counselling being done rn.-r'es 0 No
Planning F4. 2 Postpartum IUCD insertions being done 0 Yes i9--'1'Jo
FS. Client
F4.3
F4.4
F4.5
F.5.1
Interval IUCD insertions being done
Steri lization proce dures being done (Fixed Day Services or Fixed day Camps)
Postpartum st erilization being done
Privacy during delivery?
I I
I I
f )..._. ) ,( ," l/"'
. A I JLl_rufY
f IIV I V
0 G 0
0
Yes B-rlo 0 NA
Yes D--No Yes CD-No
Yes 0 No Satisfaction F.5.2
F.5.3
Is transport being provided for drop back?
Staff was well behaved with you during your stay?
I I
I \.
0 Yes
._Q_yes
0
0
No
No
F.5.4 Were you informed about the procedures before they were undertaken 0---Yes 0 No
F.5.5 Free diet provided? .a-,yes (!---1i:fo
F.5.6 Would you suggest visiting this fa cility to your relatives/friends? ID---Yes D No
,. F6. Facility ~F6.1 Is utilization of untied fund adequate? D Yes D No \ rv A mechanisms
F6.2 Awareness generation (use of IEC/BCC)- Posters, audio visual aids, display of citizen charter? D Yes D Noand others \ F6.3 Is grievance redressal mechanism in place? ID--Tu D No \
F7 F 7.1 xclusive breastfeeding practised upto six months (no water) D Yes D No Functionality F.7.2 Complementary feeding practised /) D Yes D No/
~ --- ' )
J of programs
F.7.3 ORS and Zinc available with ASHAs and distributed in community I ?-"'e,.- ':,.~ D---Yes D Noat community \ y
F.7.4 Growth monitoring at AWW centers and VHNDs ~ g-yes D No F.7.5 Malnourished children referred to Nut ritional Rehabi litation Centres CVY'es D No F.7.6 Incentives to ASHAs for delaying and spaci ng of births
/ D Yes D No
F.7.7 Incentives to ASHAs for accompanying clients for PPIUCD insertions I rviA-- "' ,,_:r ~ s ,,.l,,,,__~ ....J-.o '1Yd" . ~)L.'~) D Yes D No ,,rv v tt~ .F.7.8 Weekly IFA supplementation (WIFS) '-- V
I!) Yes Q/No F 7.9 Community based distribution of Misoprostol for PPH prevention D Yes~ D NA
F7.10 Home-based new born care by ASHA 0----ffl O No
F.7.11 HBNC kits available with ASHA -0.----'r'es D No
F7.12 Referrals of sick newborns or newborns with danger signs being undertaken D Yes D No
F.7.13 Home delivery of contraceptives by ASHAs ~D No D NA F.7.14 Menstrual hygiene practices being promoted g.-yes D No D NA F.7.15 VHNDs being conducted on a monthly basis (Services include ANC, Growth Monitori ng, Immunization, Health Messages etc) ,0"'ves D No F7.16 JSSK (JSSK entitlements being given?) D Yes aYNo F7.17 JSY (JSY entitlem ent s being given?) D Yes o-No
F7.18 Rashtriya Bal Swasthya Karyakram operational D Yes~
Major findings from last visit
Action taken on interventions/
activities identified from last visit
Plan of Action
Major findings from this visit Intervention/ Activities identified Level of intervention Responsibility Timeline
Reproductive Health/Family Planning Maternal Health
Newborn Health
Child Health
Adolescent Health
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