Checklist for Monitoring 24 X 7 PHC

Name of the State :- _________________________________________________________

Name of the District
Name of the Block
Name of the 24x7 PHC
Address
Population covered
by 24x7 PHC (in numbers)
Total number of beds
Name & Designation of
the Head of the institute
Contact Details
Date of Visit
Name & Signature of the
person collecting information :- __________________________________________________________
:- _________________________________________________________
:- _________________________________________________________
:- _________________________________________________________
:- _________________________________________________________
:- _________________________________________________________
:- _________________________________________________________
:- _________________________________________________________
:- Office :- ___________________ Mobile :- ___________________
Email :- _______________________________________________
:- ________________

I Manpower
Personnel Recommended Sanctioned In Position Remarks
1 Medical Officer * 2
2 Pharmacist 1
3 Nurse-Midwife (Staff Nurse) ** 3
4 Health Worker (Female) 1
5 Health Assistant (1 male & 1 female) 2
6 Laboratory Technician 1
7 Driver (vehicles may be out-sourced) Optional
* One may be from AYUSH and one other Medical Officer preferably a Lady Doctor
** For 24 hour PHC’s, 2 may be contractual

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

Name of the Period of
Name of the Personnel & Contact Details
Training Received posting in the
Designation (Ph & Email)
with the Date PHC
1
2
3
4
5
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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?
What did you like most about the training that you received?
4
(put √ mark)
• Content
• Training Methodology Used
• Training skills
• Practical demonstration
• Training Environment
• Field Visits
• Accommodation & Food
Kindly state in detail
Any component (from the options above) of training that you
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are not satisfied with?

6 Any training materials given to you?

7 Are those materials available in the 24 X 7 PHC?
Do you feel the training that you received is beneficial to you
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in service delivery?

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

Are you unable to utilize the skills learnt during the training at
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work place
11 If Yes, Give the Reasons (put √ mark)
12 • Inadequate training
• Lack of Infrastructure
• Lack of Drugs and Equipments
• Lack of supporting staff
• Administrative Problems
Any other training that you feel will be beneficial for your
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work? ( List the name of the trainings)

14 Any suggestions regarding training

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IV Facility Monitoring for PHC
A Infrastructure
Yes/No/
Functional (mark F)/
Questions Remarks
Non-Functional
(mark NF)
Is a designated Government building available for the
1
PHC?
2 Where is this PHC 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 Is family Welfare Clinic available?
6 Waiting room for patients available?
7 Emergency Room/Casualty available?
8 Separate wards for males and females available?
Fully furnished & equipped Labour room available?
9
(as per Annexure 1 enclosed)
If Labour room is present, are deliveries carried out in the
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Labour room 24x7 PHC?
11 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
If deliveries not being conducted 24x7, then what are the
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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
Are separate areas for septic and aseptic deliveries
13
available?
14 Is operation theatre available?
If operation theatre is present, are surgeries carried out in
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the operation theatre?
Is Operation Theatre used for obstetric/gynecological
16
purpose?
If operation theatre is present, but surgeries are not being
17
conducted there, then what are the reasons for the same?

3
 • Non-availability of doctors /staff
• Lack of equipment / poor physical state of the
operation theatre
• No power supply in the operation theatre
• Any other reason (specify)
18 Ancillary Rooms - Nurses rest room available?
19 Are laboratory facilities available?
20 Is proper water supply available?
21 Is regular power supply available?
22 Is power back up available?
Are separate toilets for males and females available and
23
functional?
24 Is Store room available?
25 Is Kitchen available in the PHC?
26 Does the PHC provide diet to the patient?
27 Are colour coded containers for waste disposal available?
28 Is bio-medical waste pit available?
29 Laundry facility available?
30 Is Telephone facility available and functional?
31 Computer available?
Is transport facility for movement of staff available and
32
functional?
Is residential facility for the staff available with all
33
amenities available?
• Medical Officer
• Pharmacist
• Nurses
• Other staff
Are essential drugs available?
34
(as per Annexure II enclosed)
Is transport (Ambulance) for referral available and
35
functional?
36 Name of the nearest referral centre (Mention the distance)

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V Health Services Yes / No Remarks

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A Assured Services available
• OPD Services
• Emergency services (24 x7)
• Referral Services
• In-patient Services
B Maternal Health Services
1 Ante-natal Care
• Are antenatal clinics organized by the PHC regularly?
• Is the Antenatal care provided?
(Inj. T.T, IFA tablets, weight and BP checkup and Hb estimation)
2 Intra-natal Care
• Is the facility for normal delivery available 24X7 in the PHC?
If Yes
 Hand Washing facility available and utilized
 Sterilized gloves used
• Is the facility for assisted deliveries available in the PHC for
24 hours?
• Managing Labour using Partograph
(Ask to show for last delivery conducted)
• Identification & Management of danger signs during Labour
• Pre-referral treatment for PPH, Eclampsia & Sepsis
• Minimum 48 hours of stay post delivery
• Is the facility for referral of complicated cases of
pregnancy/delivery available 24X7 at PHC?
• Are the facilities under Janani Suraksha Yojana provided?
3 Post-natal care (Essential)
• Breast Feeding (within 1 Hour of Birth)
• Advise Mother on Exclusive Breast feeding
Is treatment for anemia given to both pregnant as well as non-
4
pregnant women?
5 Syndromic management of RTI/STI done
Is the facility for internal examination for gynecological conditions
6
available at the PHC?
Is the treatment for gynecological disorders like leucorrhoea,
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menstrual disorders available at the PHC?
8 Is the facility for MTP (Abortion) available at the PHC?

C Family Planning Services

• Is IUCD inserted?
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 • Are the OCP, emergency pills and condoms distributed?
• Is the facility for Tubectomy and Vasectomy available at the
PHC?
D Child Health Services
Essential New Born Care
• Prevention of Hypothermia (KMC)
• Maintain airway & breathing
• Cord Care
• Eye Care
Immunization services ( If Yes )
• Are the Immunization services as per Government schedule
• Hub cutter used
• Proper disposal of sharps
Care of Sick Children
• Is the management of children suffering from diarrhea with
severe dehydration done at the PHC?
• Is the treatment of minor illness like fever, cough, cold, worm
disinfestation etc. available
• Is the treatment of children with pneumonia available at the
PHC?
• Is VHND organized every month? ( If Yes )
 Is the growth of infants and children monitored
 Nutrition Counselling provided
E Adolescent Health
• TT Immunization
• IFA Tablets
• Nutrition Counselling
• Counselling for menstrual hygiene and menstrual disorders
• Counselling for RTI/STI
F Disease Control
• Is the facility for taking peripheral blood smear in case of
fever available?
• Is it a DOT centre?

IV Investigation Services
Laboratory Services
Name of the Tests Yes/No Remarks
7
 1 Hb
Preparing blood smear for -
• Malaria Parasite
• Others (Rapid test for Malaria etc)
2 Urine
• Albumin
• Sugar
• Pregnancy test
3 BT/CT
4 Blood Sugar
5 Blood Grouping (Rh typing)
6 Blood Cross Matching
7 Diagnosis of RTI/STDs with wet mounting, grams stain, etc.
8 Sputum testing for TB
9 VDRL
10 RPR test for Syphills / YAWS surveillance
11 Rapid tests for HIV
Radiology Services
1 X Ray

Annexure I

PHC 24 x 7

List of Furnitures in Labour Room

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Sr.No. Item Yes/No Remarks
1 Examination Table
2 Delivery Table
3 Footstep
4 Bed Side Screen
5 Stool for patients
6 Arm board for adult & child
7 Saline stand
8 Wheel chair
9 Stretcher on trolley
10 Oxygen trolley
11 Height measuring stand
12 Iron bed
13 Bed side locker
14 Dressing trolley
15 Mayo trolley
16 Instrument cabinet
17 Instrument trolley
18 Bucket
19 Attendant stool
20 Instrument tray
21 Chair
22 Wooden table
23 Almirah
24 Swab rack
25 Mattress
26 Pilow
27 Waiting bench for patients / attendants
28 Medicine cabinet
29 Side rail
30 Rack
31 Bed side attendant chair

List of Equipments and consumables

S.No. Item Yes/No Remarks

1 Basin 825 ml., (Stainless Steel)
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 2 Basin deep (capacity 6litre)
3 Tray instrument/Dressing with cover
4 Flashlight
5 Torch (ordinary
6 Dressing Drum. with cover
7 Hemoglobinometer –set Sahli type
8 Weighing Scale, Adult
9 Weighing Scale, Infant
10 Weighing Scale, (baby)
11 Tissue Forceps
12 Sterilizer
13 Surgical Scissors straight
14 Sims Uterine Depressor/Retractor
15 Measuring Jug
16 Surgeon’s Scrubbing Brush with white
Nylon
Bristles
17 Sphygmomanometer
18 Kelly’s hemostat Forceps straight
19 Vulsellum Uterine Forceps curved
20 Cusco’s/Graves Speculum vaginal bi-
valve
21 Sims Speculum vaginal double ended
22 Uterine Sound
23 Cheatle’s Forcep
24 Vaccine Carrier
25 Ice pack box
26 Sponge holder
27 Plain Forceps
28 Suture needle straight & curved
29 Clinical Thermometer oral & rectal
30 Room Heater/Cooler for immunization
clinic with
electrical fittings
31 Foetoscope
32 Dressing Forceps (spring type
33 Artery Forceps, straight,
34 Cord cutting Scissors
35 Stethoscope
36 HUB Cutter
37 Ambu Bag
38 Measuring Tape
39 I/V Stand
40 Tracking Bag and Tickler Box
(Immunization)

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 Annexure II

Essential Obstetric Care Drugs Kit for PHC

Sr.No. Item Yes/No Remarks

1 Diazepam Injection
2 Lignocaine Injection
3 Pentazocine Injection
4 Dexamethasone Injection
5 Promethazine Injection
6 Methylergometrine Injection
7 Paracetamol Tablets
8 Theophylline Inj
9 Tab Co-trimoxazole
10 Adrenaline Injection
11 Amoxycillin Capsules
12 Metronidazole Tablets
13 Atropine Injection
14 Fluconazole Tablets
15 Methyldopa Tablets
16 Oxytocin Injection
17 Phenytoin Injection
18 Dextrose Injection

Drug for RTI/STI-

Sr.No. Item Yes/No Remarks

1 Ciprofloxacin Hydrochloride Tablets
2 Doxycycline Hydrochloride Capsules
3 Erythromycin Estolate Tablets
4 Benzathine Penicillin Injection
5 Tinidazole Tablets
6 Clotrimazole Cream & pessary
7 Clotrimazole Cream 2%
8 Gramma Benzene Hexachloride
Ointment
9 Distilled Water Ampoules

Drugs and Consumables for MVA:

Sr.No. Item Yes/No Remarks

1 Chlorine solution
2 Antiseptic solution (savlon)
3 Local Anaesthetic agent
(injection1%Lignocaine)
4 Sterile saline/sterile water

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