8/7/2019 5.PHC 24 X 7 5th Jan 11
1/12
8/7/2019 5.PHC 24 X 7 5th Jan 11
2/12
III Feedback of Trained PersonnelName of Trained Personnel :-Name & Date of the last training received :-
Questions Yes/No Remarks1 Was the purpose/objective of taking the training fulfilled?
2 Was the duration of the training was sufficient?
3 Was the course content sufficient?
4What 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
5Any component (from the options above) of training that youare not satisfied with?
Kindly state in detail
6 Any training materials given to you?
7 Are those materials available in the 24 X 7 PHC?
8Do you feel the training that you received is beneficial to youin service delivery?
9 If No, Give the Reason (List out the problems)
10Are you unable to utilize the skills learnt during the training at
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
13 Any other training that you feel will be beneficial for yourwork? ( List the name of the trainings)
14 Any suggestions regarding training
2
8/7/2019 5.PHC 24 X 7 5th Jan 11
3/12
IV Facility Monitoring for PHC
A Infrastructure
Questions
Yes/No/Functional (mark F)/
Non-Functional(mark NF)
Remarks
1Is a designated Government building available for thePHC?
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?
9Fully furnished & equipped Labour room available?(as per Annexure 1 enclosed)
10If Labour room is present, are deliveries carried out in the
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
12If deliveries not being conducted 24x7, then what are the
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
13Are separate areas for septic and aseptic deliveries
available?
14 Is operation theatre available?
15If operation theatre is present, are surgeries carried out in
the operation theatre?
16Is Operation Theatre used for obstetric/gynecological
purpose?
17
If operation theatre is present, but surgeries are not being
conducted there, then what are the reasons for the same?
3
8/7/2019 5.PHC 24 X 7 5th Jan 11
4/12
Non-availability of doctors /staff
Lack of equipment /poor physical state of theoperation 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?
23Are separate toilets for males and females available and
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?
32Is transport facility for movement of staff available and
functional?
33Is residential facility for the staff available with allamenities available?
Medical Officer
Pharmacist
Nurses
Other staff
34Are essential drugs available?
(as per Annexure II enclosed)
35Is transport (Ambulance) for referral available andfunctional?
36 Name of the nearest referral centre (Mention the distance)
4
8/7/2019 5.PHC 24 X 7 5th Jan 11
5/12
V Health Services Yes / No Remarks
5
8/7/2019 5.PHC 24 X 7 5th Jan 11
6/12
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
4Is treatment for anemia given to both pregnant as well as non-
pregnant women?
5 Syndromic management of RTI/STI done
6Is the facility for internal examination for gynecological conditions
available at the PHC?
7Is the treatment for gynecological disorders like leucorrhoea,
menstrual disorders available at the PHC?
8 Is the facility for MTP (Abortion)available at the PHC?
C Family Planning Services Is IUCD inserted?
6
8/7/2019 5.PHC 24 X 7 5th Jan 11
7/12
Are the OCP, emergency pills and condoms distributed?
Is the facility for Tubectomy and Vasectomy available at thePHC?
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 ServicesName of the Tests Yes/No Remarks
7
8/7/2019 5.PHC 24 X 7 5th Jan 11
8/12
1 Hb
Preparing blood smear for -
Malaria Parasite
Others (Rapid test for Malaria etc)
2 Urine
Albumin
Sugar
Pregnancy test3 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
8
8/7/2019 5.PHC 24 X 7 5th Jan 11
9/12
Sr.No. Item Yes/No Remarks1 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 rail30 Rack
31 Bed side attendant chair
List of Equipments and consumables
S.No. Item Yes/No Remarks1 Basin 825 ml., (Stainless Steel)
9
8/7/2019 5.PHC 24 X 7 5th Jan 11
10/12
2 Basin deep (capacity 6litre)
3 Tray instrument/Dressing with cover
4 Flashlight
5 Torch (ordinary6 Dressing Drum. with cover7 Hemoglobinometer set Sahli type
8 Weighing Scale, Adult
9 Weighing Scale, Infant
10 Weighing Scale, (baby)
11 Tissue Forceps12 Sterilizer13 Surgical Scissors straight14 Sims Uterine Depressor/Retractor
15 Measuring Jug
16 Surgeons Scrubbing Brush with whiteNylonBristles
17 Sphygmomanometer
18 Kellys hemostat Forceps straight
19 Vulsellum Uterine Forceps curved20 Cuscos/Graves Speculum vaginal bi-valve
21 Sims Speculum vaginal double ended
22 Uterine Sound23 Cheatles Forcep24 Vaccine Carrier
25 Ice pack box
26 Sponge holder
27 Plain Forceps
28 Suture needle straight & curved
29 Clinical Thermometer oral & rectal30 Room Heater/Cooler for immunization
clinic withelectrical fittings
31 Foetoscope32 Dressing Forceps (spring type33 Artery Forceps, straight,34 Cord cutting Scissors
35 Stethoscope
36 HUB Cutter
37 Ambu Bag38 Measuring Tape39 I/V Stand40 Tracking Bag and Tickler Box
(Immunization)
10
8/7/2019 5.PHC 24 X 7 5th Jan 11
11/12
Annexure II
Essential Obstetric Care Drugs Kit for PHC
Sr.No. Item Yes/No Remarks1 Diazepam Injection
2 Lignocaine Injection
3 Pentazocine Injection
4 Dexamethasone Injection
5 Promethazine Injection6 Methylergometrine Injection7 Paracetamol Tablets
8 Theophylline Inj
9 Tab Co-trimoxazole
10 Adrenaline Injection
11 Amoxycillin Capsules12 Metronidazole Tablets13 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 Remarks1 Ciprofloxacin Hydrochloride Tablets
2 Doxycycline Hydrochloride Capsules
3 Erythromycin Estolate Tablets
4 Benzathine Penicillin Injection5 Tinidazole Tablets6 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 Remarks1 Chlorine solution2 Antiseptic solution (savlon)3 Local Anaesthetic agent
(injection1%Lignocaine)4 Sterile saline/sterile water
11
8/7/2019 5.PHC 24 X 7 5th Jan 11
12/12