Attendance

Morning / Take Picture

1 APMO
2 SMO/SWMO
3 MO
4 WMO
5 Dental Surgeon
6 Dental Technician
7 Midwife/Dai
8 Charge Nurses
9 Lab Technician
10 Lab Assistants
11 Computer Operator
12 Dresser
13 X-Ray Technician
14 Senior Clerk
15 Dispenser
16 Operation Theater Assistant
17 Anesthesia Assistant
18 Ward Servant
19 LHV
20 Sanitary Patrol
21 Vaccinator
22 Homeo-Dispenser
23 Homeo Doctor
24 Hakeem
25 Cook
26 CDC Supervisor
27 Water Carrier
28 Medical Technician
29 Sanitary Worker
30 Maali
31 Naib Qasid
32 LHS
33 LHS Driver
34 Tube well Operator
35 Dwa Cobe
36 Chowkidar
Attendance
Leave Authorized
Late Comer By whom
C.L M.L E.L EOL Yes No allowed
(If authorized)
 Vacancy Position
Sr. No Indicator Sanctioned Filled Vacant General Duty In
1 APMO 1
2 SMO/SWMO 2
3 MO 3
4 WMO 1
5 Dental Surgeon 1
6 Dental Technician 1
7 Midwife/Dai 4
8 Charge Nurses 6
9 Lab Technician 1
10 Lab Assistants 1
11 Computer Operator 1
12 Dresser 2
13 X-Ray Technician 1
14 Senior Clerk 1
15 Dispenser 4
Operation Theater
16 1
Assistant
17 Anesthesia Assistant 1
18 Ward Servant 4
19 LHV 2
20 Sanitary Patrol 4
21 Vaccinator 1
22 Homeo-Dispenser 1
23 Homeo Doctor 1
24 Hakeem 1
25 Cook 1
26 CDC Supervisor 1
27 Water Carrier 1
28 Medical Technician 1
29 Sanitary Worker 4
30 Maali 1
31 Naib Qasid 2
32 LHS 1
33 LHS Driver 1
34 Tube well Operator 1
35 Dwa Cobe 1
36 Chowkidar 2
General Duty Out EOL EL
Display
Sr. No Indicators Yes No
1 Duty roster Displayed
2 Expected Delivery Date (EDD) List Displayed
3 Hand washing posters in MO Room (preferably near sink) Displayed
4 LHW referral register Displayed
5 Waste Segregation Posters Displayed
6 Checkup manual displayed
7 Patient manual displayed
8 EPI Charts
9 Population Catchment area
10 Direction Signboard in the facility
11 Organogram
12 Mission Statement
13 Contact information of Referral Centers in LHV and Labour Room Displayed
14 Complaint Management System Awareness Material Displayed
Picture
Utilities
Sr. No Indicator Yes No
1 Electricity Status
2 Sewerage system Status
3 Sui gas Status
4 Telephone Status
5 Water supply system Status
Facilty Outlook
Sr. No Indicators Poor Avg. Good Excelent
1 Boundary wall Condition
2 Building Condition Condition
3 Disposal of hospital waste Condition
4 Labor Room Toilet Condition
5 Labour room Condition
6 Lawns Condition
7 Patient ward toilet Condition
8 General Toilet Condition
9 Road-sign board condition
10 Sign-board outside the facility condition
11 Staff residences Condition
12 Waiting area Condition
13 Wards Condition
14 Whitewash Condition
15 Separate Female toilet condition
16 Is burialpit developed per standard
Picture
 Medicine & Supplies
Sr. No
Name of Medince
1 Anti-Histamine Tab/Chlorpheniramine maleate Tablets 4 mg
2 Atenolol Tab
3 Cap. Amoxicillin/Ampicillin
4 Condoms
5 Contraceptive injections
6 Copper-T
7 Drotaveine tab
8 Glibenclamide Tab
9 I/V Infusions/Dextrose infusion/Normal saline
10 Inj Diclofenac Sodium
11 Inj. Adernaline
12 Inj. Aminophyline
13 Inj. Hamacel
14 Inj. Hydrocortisone
15 Inj. Magnesium Sulfate
16 Inj. Ringer Lectate
17 Inj. Soda Bicarv
18 Inj. Transamine
19 Salbutamloe Solution (Ventoline Solution)
20 Inj. CPM / Avil
21 Inj. Dexamethasone Sodium Phsophate
22 Inj. Oxytocin
23 Injection Ampicillin/Amoxicillin/Augmentin/ Gentamycin/Ceftriaxone
24 Metformin 500mg-Tab
25 Omeprazole Tab 20mg
26 Oral Contraceptive Pills (COC)
27 ORS (Packets)
28 Syp. Amoxicillin/Ampicillin/Cephradine/Amoxicillin
29 Syp. Antihelminthic (Albendazole/Mebendazole)
30 Syp. Cotrimoxazole/Erythromycin
31 Syp. Metronidazole
32 Syp. Paracetamol/Ibuprofen/Mefenemic acid
33 Tab Diclofenac/Paracetamol/Ibuprofen/Mefenemic acid
34 Tab. Zink DT
35 Tab. Chloroquin/Artemether
36 Tab. Cotrimoxazole/Ofloxacin/Ciprofloxacin/Erythromycin/Doxycycline 100mg
37 Tab. Iron/Folic acid
38 Tab. Metronidazole
39 Tab. Amoxil DT
40 Tab. Methyl dopa (Aldomate)
41 Tab. Misoprostol

Supplies
1 Bandages
2 Disposable Syringes
3 Cotton roll
4 Suture
5 Disposable Gloves
6 IV Branula
7 IV Set
8 Antiseptic Solution
9 AD Syringes
10 Surgical Gauze
11 Sticking Plaster
12 Blood Glucose Test Strips
13 HBV Strips
14 HCV Strips
15 Pregenancy Strip Test Kits
 Medicine Target
Last Month Balance at time (3 X Last month
Consumption of Visit Consumption)
 Vaccine and Logitics
Sr. No Last Month
Name of Medince Consumption
1 BCG
2 Hepatitis-B birth dose
3 IPV
4 Measles
5 OPV
6 Pentavalent
7 Pnuemococal
8 ROTA
9 AD Syringes
10 TT
 Balance at
time of Visit Vaccine Target
 Equipments

Sr. No
Standard
Number
Name of Euipment
List of Medical Equipments
1 Nebulizer
2 Oxygen Cylinders
3 Refrigerator/Iceliner for vaccine
4 Sharp Container
5 Ambu Bag
6 BP Apparatus
7 Delivery Light
8 Delivery Set
9 Delivery Table
10 Hospital Beds
11 Ice-packs for vaccines
12 Infant Ambu Bag
13 Adult Weighing Machine
14 Air conditioner for operation theater
15 Autoclave/ Sterlizers
16 Baby Resucitation Trolley
17 Bulb Sucker
18 Centrifuge
19 Chemistry Analyzer (for liver and renal tests)
20 Dental Unit
21 Dental X-Ray Machine
22 ECG Machine
23 Emergency tray with life saving medicines
24 Episiotomy Set
25 Examination Beds
26 Fetal heart detector
27 General surgey instrument set
28 Hematology Machine/CBC Analyzer (for blood test)
29 IUD Kit
30 Slides
31 Sterilizer
32 Sucker
33 Thermometer
34 Ultrasound Machine
35 X-Ray Machine
36 Generator
37 Microscope
38 Reagents
39 Infant Weighting Machine
40 Thermometer for vaccine fridge
List of Non-Medical Equipments
1 Wheelchair Functional
2 3-seater steel benches
3 Bedsheets
4 Blankets
5 Exhaust fans in the bathroom
6 Flush tanks in the bathroom
7 Fans In Delivery Room
8 Fans In Ward
9 Fans In Waiting Area
10 Fans In LHV Room
11 Lights In Delivery Room
12 Lights In Ward
13 Lights In Waiting Area
14 Lights In LHV Room
15 Backup Power (UPS)
16 Heater Functional
17 Water dispenser
18 Computer
19 Printer
20 Biometric Device
21 Security Gate
22 Operation Theater ceiling light
23 Operation Theater table
24 Generator
 Non-
Available Functional
Functional
Outpatient Theraputic Program

Equipments
Sr. No Name of Item Standard Available Functional
1 MUAC Tape (Child)
2 MUAC Tape (Adult)
3 Electronic Weighting Machine
4 Height Measuring Board
5 Length Measuring Board (Child)

Medicines
Medicine
Sr. No Target
Last Month Stock (3 X Last month
Name of Item Consumption Available Consumption)
1 Syp. Chloroquine
2 Plumpy Nuts
3 Syp. Zinc Sulphate
4 ORS
5 Syp. Paracetamole 120 mg/5ml
6 Syp. Amoxicilline
7 Tab. Folic Acid

Display
Sr. No Name of Item Yes No
1 Breast Feeding Corner Established
2 Fan in breastfeeding corner
3 Bench / Chair
4 Screen / Curtain
5 RUTF weight chart
Outpatient therapeutic program
6
Protocol Chart
Non-Functional
 Facility Indicator
Performance Indicators Last Month At the time of Visit
1 OPD
2 OPD <5 years during last month
Patients Referred to other Health
3 Facilities
4 Referred Patients Attended
5 Number of deliveries conducted
6 Number of family planning clients
7 Copper-T Insertion
8 Number of children revceived BCG
9 Number of ANC Visits
10 Number of ANC-Revisits
11 Number of deliveries referred

Vaccination

Sr. No Indicator
Last Month At the Time of Visit
At HF Outreach At HF
1 BCG
2 Hepatitis-B birth dose
3 Measles-I
4 Measles-II
5 Pentavalent-III
6 ROTA
7 TT-I
8 TT-II
t the time of Visit

t the Time of Visit