Month:________ Year:____ DHIS-21(MR)

Total Working Days:___

PHC Facility Monthly ReportDistrict: Sialkot Date of /2018
submission

Section I: Identification
1 Facility ID 1 4 4 0 5 6 4. Signature of Facility In-
.
charge:
2 Facility Name BHU PINDI
. BHAGO
3 Tehsil PASRUR 5. Designation:
.
Section II: Monthly performance (Number or % Monthly Target performance
asappropriate)
1. Daily OPD attendance 52
2. Full immunization coverage 58
3. Antenatal care (ANC-1) coverage 31
4. Monthly report data accuracy 95%
5. Delivery coverage at facility 12
6. TB-DOTS patients missing more than one week 5%
7. Total visits for FP 59
8. LHW pregnancy registration coverage 35

Section III: OutpatientsAttendance(From OPD <1 Yrs 1-4 Yrs 5-14 Yrs 15-49 50+ Total
Register) Yrs Yrs
1. Male (New cases)
2. Female (New cases)
Grand Total
3. Follow up cases 4. Referred cases attended(SH&NS,LHWs)
5. Total Homeo 0 6 Total Tibb/Unani 0 7 No. of Cases. of Malnutrition <5 Yrs
children

Section IV: Cases attending OPD(From OPD Abstract Endocrine Diseases

Form)
Respiratory DiseasesalGgas ory Diseases 28 Diabetes Mellitus
1 Acute (upper) respiratory infection Neuro-Psychiatric DiseasesalGgsychiatric
Diseases
2 Pneumonia <5 Yrs 29 Depression
3 Pneumonia >5 Yrs 30 Drug Dependence
4 TB Suspects 31 Epilepsy
5 Chronic Obstructive Diseases Eye & ENT
6 Asthma 32 Cataract
Gastro Intestinal DiseasesalGgas Diseases 33 Trachoma
7 Diarrhoea / Dysentery <5 Yrs 34 Glaucoma
8 Diarrhoea / Dysentery .5 Yrs 35 Otitis Media
9 Enteric / Typhoid Fever Oral Diseases
10 Worm Infestations 36 Dental Carries
11 Peptic Ulcer Diseases Injuries/Poisoning /Poisoning
12 Cirrhosis of Liver 37 Road Traffic Accident
Urinary Tract DiseasesalGgas rinary Tract Diseases 38 Fractures
13 Urinary Tract Infections 39 Burns
14 Nephritis / Nephrosis 40 Dog Bite
15 Sexually Transmitted Infections 41 Snake Bite(With signs/ symptoms of poisoning)
16 Benign Enlargement of Prostate Miscellancous Diseases llaneous Diseases
Other Communicable Diseases 42 Acute Flaccid Paralysis
17 Suspected Malaria 43 Suspected HIV/AIDS
18 Suspected Meningitis Any Other Unusual Diseases (Specify)
19 Fever Due to Other causes 44 Suspected Dengue Fever
Vaccine Prevantive Diseasesa 45 Suspected Swine Flu
20 Suspected Measles 46 Suspected Avian Flu
21 Suspected Viral Hepatitis 47 Suspected Acute Watery Diarrhea
22 Suspected Neo Natal Tetanus 48 Bloody Diarrhea
Carddivascular Diseases 49 Suspected Diphtheria
23 Ischemic Heart Diseases 50 Suspected Pertussis
24 Hypertension Suspected Viral Hemorrhagic
51 Fever(CCHF)
Skin Diseases
25 Scabies 52 Silicosis (Lung Disease)
26 Dermatitis 53 Chicken Pox
27 Cutaneous Leishmaniasis 54 Other (Please Specify)

Section V- Immunization( From EPI Register)

Children<12 months received 3rd Pentavalent 3. Children >12 months fully immunized
1. vacc.

Children<12 months rcvd. 1st Measles 4. Pregnant women received TT -2 vaccine

2. vaccine

Section VI: TB-DOTS(From TB Card TB-01)

Intensive-phase TB-DOTS Intensive phase TB-DOTS patients missing treatment
1. 2.
patients >1 week

Section VII: Family Planning Services/Commodities provided (From FP 7. IUCD

Register)
1. Total FP visits 4. DMPA Inj. 8. Tubal Ligation
2. COC cycles 5. Net-En Inj. 9. Vasectomy
3. POP cycles 6. Condom Pieces 10. Implants

Section VIII: Maternal and Newborn Health(From Maternal Health & Obstetric Registers)
1st Antenatal Care visits (ANC-1) in the Vacuum / Forceps deliveries in
1. 6.
facility facility
2. ANC-1 women with Hb. <10 g/dl 7. Live births in the facility
3. Antenatal Care revisit in the facility 8. Live births with LBW( < 2.5kg)
st
4. 1 Postnatal Care visit (PNC-1) in the facility 9. Stillbirths in the facility
5. Normal vaginal deliveries in facility 10. Neonatal deaths in the facility

Section IX: Community Based Data

(From LHW Report) 4. Infant deaths reported
Pregnant women newly registered by
1. No. of modern FP method users
LHW 5.
2. Delivery by skilled persons reported 6. <5 year diarrhea cases reported
3. Maternal deaths reported 7. < 5 year ARI cases reported

Section X: Community Meetings

Male
(From Community Meeting Register) 2. No. of Participant
1. No. of community meetings Female

Section XI: Diagnostic Services( From Laboratory Register / TB Lab Register/ Radiology Register) (For RHC
ONLY)

Services Provided OPD Indoor Services Provided OPD Indoor

0 0 0
1. Total Lab Investigations 3. Total Ultra Sonographies 0
0 0 0
2. Total X-Rays 4. Total ECGs 0
Laboratory Investigation for Communicable Diseases
Malaria T.B Viral Hepatitis
Slides for AFB Diagnosis Patients
1.
1. Slides Prepaired 1. screened
Diagnosis slides with AFB
2.
2. Slides MP +ve +ve 2. Hepatitis B +ve
Slides P. falciparum Follow-up slides for AFB
3.
3. +ve 3. Hepatitis C +ve
Follow-up slides with AFB
4.
+ve
Section XII-A: Stock out Report: Stock out of tracer drugs for any number of days this month
(From Stock Register for Medicine/ Supplies) Tick where applicable
1. Cap. Amoxicillin 7. Inj. Ampicillin 13. Syp. Antihelminthic
2. Syp. Amoxicillin 8. Tab. Diclofenac 14. I/V infusions
3. Tab. Cotrimoxazole 9. Syp. Paracetamol 15. Inj. Dexamethasone
Tab. Iron/ Folic
4. Syp. Cotrimoxazole 10.
Inj. Diclofenac 16. Acid
5. Tab. Metronidazole 11.
Tab. Chloroquin 17. ORS
6. Syp. Metronidazole 12.
Syp. Salbutamol 18. Oral pills (COC)
Section XII-B: Stock out Report: Vaccines (Tick where applicable)
1. BCG vaccine 4. Hepatitis-B vaccine 7. Anti Rabies Vaccine 1
2. Pentavalent vaccine 5. Measles vaccine 8. Anti Snake Venom 1
3. Polio vaccine 6. Tetanus Toxiod 9. Vaccine Syringes 0

Section XIII-A: Indoor Services(From Daily Bed Statement Register) (For RHC ONLY)
Discharged/ Discharged/ Total of Average
Allocated DOR (not on DOR on same Daily Bed Length of
Admissions LAMA Referred Deaths
Beds the same day day of Patient Occupancy Stay
of admission) admission Count (ALS)
1. Male %
2. Female %

Section XIII-B: Cases Attending Indoor Total Number of

Total Number of Deaths
( From Indoor Register / Obstetric Register)(For RHC ONLY) Admissions
1. Diarrhea/Dysentery in < 5 yrs. 0 0
2. Pneumonia in <5 yrs. 0 0
3. Malaria 0 0
4. Pulmonary Tuberculosis 0 0
5. Maternal deaths in the facility 0 0
6. Other causes 0 0
Total 0 0

(For RHC
Section XIV: Surgeries(From OT Register) ONLY)
1. Operations under GA 0 3. Operations under LA 0
2. Operations under Spinal 0 4. Operations under other type of
Anesthesia Anesthesia 0

Section XV: Human Resource Data ( From Facility Records)

 On General
Sanctione Contrac On General
Post Name/Category Vacant duty in Facility
duty out of
d t Facility
1 Senior Medical Officer 0 0 0 0 0
2 Medical Officer 0 0 0 0 0
3 Women/Lady Medical Officer 1 0 0 0 0
4 Dental Surgeon 0 0 0 0 0
5 Head Nurse 0 0 0 0 0
6 Staff Nurse/Charge Nurse 0 0 0 0 0
7 Medical Assistant 0 0 0 0 0
8 Sanitary Inspector 1 0 1 0 01
9 Lab Assistants 0 0 0 0 0
10 Dental Assistant 0 0 0 0 0
11 X-Ray Assistant 0 0 0 0 0
12 Lady Health Visitor 2 0 01 0 01
Health Technician/Medical 1 01 0 0 0
13
Technician
14 Dispenser 1 0 0 0 0
15 EPI Vaccinator 0 0 01 0 0
16 CDC Supervisor 0 01 0 0 0
17 Midwife/ dia 1 02 0 0 0
18 LHW 0 19
19 Others, NS, C/O, N/Q , Chokidar, S,W 5 0 01 0 0

Section XVI-A: Revenue Generated(From Receipt Total Receipt Deposited

Register)
Total Receipt Deposited 5. X-Ray Rs. 0 0
1. OPD Rs.0 0 6. Ultrasound Rs. 0 0
2. Indoor Rs.0 0 7. Dental Rs. 0 0
Procedures
3. Laboratory Rs. 0 0 8. Ambulance Rs. 0 0
4. ECG Rs. 0 0 9. Others Rs. 0 0

Section XVI-B: Financial Report-for the Current Fiscal Year(From Budget and Expenditure Statement (For RHC
ONLY)
Total
Total Allocation for Total Budget
Expenditureto-
Released to-date
Balance to date
the fiscal year
date
1. Salary & Allowances
Rs.0 Rs.0 Rs.0 Rs.0
(Establishment charges)
2. Non-Salary (Operating
Rs.0 Rs.0 Rs.0 Rs.0
Expenses)
3. Utilities Rs.0 Rs.0 Rs.0 Rs.0
4. Medicine Rs.0 Rs.0 Rs.0 Rs.0
5. General Stores Rs.0 Rs.0 Rs.0 Rs.0
6. M&R
Rs.0 Rs.0 Rs.0 Rs.0
Equip/Transport/Furniture
7. M&R Building Dept Rs.0 Rs.0 Rs.0 Rs.0
8. Others Rs.0 Rs.0 Rs.0 Rs.0
9. Annual Development Plan Rs.0 Rs.0 Rs.0 Rs.0

Section XVII– Achievements/ Issues