Checklist for Monitoring District Hospital

Name of the State :- _____________________________________________________

Name of the District
Name of the DH
Address
Population covered
by DH (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 IPHS norms Sanctioned In Position Remarks
Clinical Manpower
1 General Surgeon 1
2 Physician 1
3 Obstetrician/Gynecologist 1
4 Paediatrics 1
5 Anaesthetist 1
6 Eye Surgeon 1
7 Orthopaedician 1
8 Radiologist 1
9 Dermatologist/Venereologist 1
Casualty Officer/
10 6
General Duty Officer
11 AYUSH Physician 2

1
12 Pathologist 1
13 Microbiologist 1
14 Forensic expert 1
Public Health Programme
15 1
Manager

Support Manpower
16 Staff Nurse 75-100
17 Pharmacist / Compounder 1
Lab. Technician
18 1
(Lab+ Blood Bank)
19 Radiographer 1

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

Name of the
Sr.No. Name of the Trained Person Designation Date
Training Received

1
2
3
4
5
6
7
8
9
10
11
12

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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 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

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you are not satisfied with?

6 Any training materials given to you?

7 Are those materials available in the DH?
Do you feel the training that you received is beneficial to you
8
in service delivery?

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

Are you unable to utilize the skills learnt during the training
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at work place
11 If Yes, Give the Reasons (put √ mark)
• 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
12
work? ( List the name of the trainings)
13 Any suggestions regarding training

3
IV Facility Monitoring for DH
A Infrastructure
Yes/No/
Functional (mark F)/
Questions Remarks
Non-Functional
(mark NF)
1 Is a designated Government building available for the DH?
2 Where is this DH located?
• Is the hospital located near residential area
• Is the hospital located in an area free from pollution
of any kind including air, noise, water and land
pollution?
• General Medical
• Obstetric & Gynecologist
• Paediatrics
• Neonatology
• Surgical
• Critical care (ICU)
• Casualty/ Emergency Room
• Ophthalmic
• ENT
• Dental
• Dermatology & Venereology
• Psychiatry
• Orthopaedic
• Infectious & Communicable Diseases located in
remote corner with independent access
9 Are separate wards for males and females available?
Fully furnished and equipped Labour room
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(as per the Annexure I) available?
If Labour room is present, are deliveries carried out in the
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Labour room round the clock?
12 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 round the clock, then what
13
are the reasons for the same?
• Shortage of staff
• Staff not staying at DH
• Poor condition of the Labour room
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 • No power supply in the Labour room
• Any other specify
14 Are separate areas for septic and aseptic deliveries available?

15 Is the Sick New Born Care Unit available?

• Bed or Bassinet
• Pediatrics Ambu Bag and Mask
• Radiant warmer
• Incubator
• Mucus sucker/ Suction machine
• Phototherapy unit
• Oxygen hood
• Pulse oxymeter
• Exchange transfusion
• Lumber Puncture
• Liver biopsy U/S guided
• Ventilator
16 Is operation theatre available?
If Yes, Is the OT located in close relation to ICU, Radiology,
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Pathology, Blood Bank?
If operation theatre is present, are surgeries carried out in the
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operation theatre?
Is Operation Theatre used for obstetric/gynaecological
19
purpose?
If operation theatre is present, but surgeries are not being
20
conducted there, then what are the reasons for the same?
• Non-availability of doctors/anaesthetist/staff
• Lack of equipment / poor physical state of the
operation theatre
• No power supply in the operation theatre
• Any other reason (specify)
21 Is Intensive Care Unit available?
• IF Yes, Is the unit located close to OT, X-Ray and
Pathology department?
22 Is X-Ray Room available?
• If Yes, Is X-Ray room accessible to OPD, Wards and
Operation Theatre?
23 Ultrasound Room
• If Yes, Is Ultrasound room accessible to OPD, Wards
and Operation Theatre?
24 Clinical Laboratory
• If Yes, Is it a fully equipped laboratory?
• Is Sample Collection Room with facility for quick
diagnosis of blood, urine, etc available?
5
25 Blood Bank
• Is it a fully equipped Blood Bank?
• Is the blood bank located in close proximity to
pathology department and at an accessible distance to
Operation Theatre, ICU, Emergency and Accident
department?
• Does the blood bank supplies blood to health facility
in the periphery?
26 Is proper water supply available?
27 Is regular power supply available?
28 Is power back up available?
29 Are Cold Chain facilities available?
• Walk-in coolers
• Walk-in freezers available
• Ice lined freezers
• Deep freezers
• Refrigerators
Are separate toilets for males and females available and
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functional?
31 Is Store room available?
32 Is Kitchen available and operational in the DH?
33 Does the DH provide diet to the patient?
34 Are colour coded containers for waste disposal available?
35 Is bio-medical waste pit available?
36 Is there an incinerator?
37 Is Laundry facility available?
38 Is Telephone facility available and functional?
Is Computer with connectivity to district health system, state
39
& national level available?
Is transport facility for movement of staff available and
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functional?
Is residential facility for the following staff with all
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amenities available? (Mention the number)
• General Surgeon
• Physician
• Obstetrician/Gynecologist
• Paediatrics
• Anaesthetist
• Eye Surgeon
• Orthopaedician
• Radiologist
• Dermatologist/Venereologist
• Casualty Officer/ General Duty Officer
• AYUSH Physician
• Pathologist
• Microbiologist

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 • Forensic expert
• Public Health Programme Manager
• Staff Nurse
• Pharmacist / Compounder
• Lab. Technician (Lab+ Blood Bank)
• Radiographer
Are essential drugs available?
42
(Annexure II enclosed)
43 Is transport (Ambulance) for referral available and functional?
44 Name of the nearest referral centre (Mention the distance)

V Health Services Yes / No Remarks

1 Are following Obs & Gynae services available?
• Normal Delivery
• Managing Labour using Partograph
(Ask to show for last delivery conducted)
• Episiotomy
• Assisted Breech Delivery
• Forceps delivery
• Assisted Twin Delivery
• Craniotomy-Dead Fetus/Hydrocephalus
• Caesarean section
• Female Sterilization
(Mini Laparotomy & Laparoscopic)
• D&C
• MTP
• Bartholin Cyst Excision
• Suturing Perineal Tears
• Cervical Cautery
• EUA
• Midtrimestor Abortion
• Ectopic Pregnancy Rupture
• Retained Placenta
• Vaginal hysterectomy
• Caesarean hysterectomy
• Suturing Cervical Tear
2 Are New-born care services available?
3 Are Emergency care of sick children services available?
4 Are the Immunization services as per Government schedule?
5 Is the facility for referral of complicated cases of pregnancy /
delivery/ sick new born & children available round the clock
at DH?
6 Are the facilities under Janani Suraksha Yojana provided?
7 Is the Syndromic management of STI / RTI available?
8 Availability of Counseling facility on HIV/ AIDS / STD etc.
9 Is it a Voluntary Council and Testing Centre (VCTC)?
10 Is it a DOTS centre?

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VI Diagnostic Services
Name of the Test Yes/No Remarks
1 Hematology
• Hb
• Total Leukocyte count
• Differential Leukocyte count
• Absolute Eosinophils count
• Reticulocyte count
• Total RBC count
• E.S.R
• Bleeding time
• Clotting time
• Prothrombin time
• Peripheral Blood Smear
• Malaria/Filaria Parasite
• Platelet Cell volume
• Blood grouping
• Rh typing
• Blood cross matching
• ELISA for HIV, HBS AG, and HCV
2 Urine Analysis
• Urine for Albumin
• Sugar
• Deposits
• Bile salts
• Bile pigments
• Acetone
• Specific gravity
• Reaction (pH)
3 Stool Analysis
• Stool for Ovacyst
• Hanging drop for V. Cholera
• Occult blood
4 Pathology
• PAP smear
• Cytology
• Sputum
• Sputum cytology
• Haematology
• Bone Marrow Aspiration
• Coagulation disorders
• Sickle cell anaemia
• Thalassemia
• Histopathology
• All types of specimens, Biopsies

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5 Microbiology
• Smear for AFB (Acid Fast Bacilli),KLB (Diphtheria Bacilli)
• Culture and sensitivity for blood, sputum, pus, urine etc.
• Stool culture for enteco pathogene
• Supply of different Specimen collection and
transportation media for peripheral Laboratories
• KOH Study for Fungus
• Grams Stain for Throat swab, sputum etc.
• Bacteriological analysis of water by Rapid H2S test to be
done in districts where there is no separate public health
laboratory
6 Serology
• Pregnancy test (Urine gravindex)
• Coomb's tests,
• Lepto spirosis (Rapid test / ELISA)
• WIDAL test
• RPR test
• Elisa test for HIV, Hb, Ag, HCV
• RA factor test
7 Biochemistry
• Blood Sugar
• Glucose Tolerance Test
• Glycosylated Hemoglobin
• Blood urea, blood cholesterol
• Serum bilirubin
• Liver function tests
• Kidney function tests
• Lipid Profile
• Blood uric acid
• Serum calcium, sodium, potassium
• Serum Phosphorous
• Serum Magnesium
• CSF for protein, sugar
• Blood gas analysis
• Estimation of residual chlorine in water by OT test
• Thyroid T3 T4 TSH
• CPK
• Chloride
8 Cardiac Investigations
• ECG
• Stress
• ECHO
9 Ophthalmology
• Refraction by using Snellen's chart
• Retinoscopy
• Ophthalmoscopy

9
10 Radiology
• X-ray for Chest, Skull, Spine, Abdomen, bones
• IITB X-Ray – CR Digital
• OPG
• HSG
• Ultrasonography Colour Doppler
• Spiral CT scan
• MRI 0.5 TESSLA
11 Endoscopy
• Oesophagus
• Stomach
• Colonoscopy
• Bronchoscopy
• Arthroscopy
• Laparoscopy (Diagnostic)
• Colposcopy
• Hysteroscopy
12 Physiology (Pulmonary function test)
• Pulmonary function tests

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 Annexure I
District Hospital

List of Furniture’s of Labour Room

Sr.No. Items Yes/No Remarks

1 Examination Table
2 Labour table with Mattress, pillow and Kelly’s pad
3 McIntosh Sheet
4 Writing Table
5 Armless chairs
6 Medicine chest
7 Labour table
8 Wooden screen
9 Foot step
10 Coat rack
11 Bed side table
12 Stool
13 Almirahs
14 Lamp
15 Side wooden racks
16 Fans
17 Tube lights
18 Basin stand
19 Buckets
20 Mugs
21 Kerosene stove
22 Sauce pan with lid
23 Water receptacle
24 Rubber / plastic shutting
25 Talquist Hb scale
26 Drum with tap for storing water
27 Hypochlorite solution/bleach
28 Black Disposal bags
29 Red Disposal Bags

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Equipments in the Labour Room
Functional (F)/
Available
Sr.No. Equipment Non Functional Remarks
(Yes/No) (NF)
1 Baby Incubators
2 Phototherapy Unit
3 Standard weighing scale
4 Newborn Care Equipments
5 Double–outlet Oxygen Concentrator
6 Radiant Warmer
7 Room Warmer
8 Foetal Doppler
9 CTG Monitor
10 Delivery Kit
11 Episiotomy kit
12 Forceps Delivery Kit
13 Crainotomy
14 Vacuum extractor metal
15 Silastic vacuum extractor
16 Pulse Oximeter baby & adult
17 Cardiac monitor baby
18 Nebulizer baby
19 Weighing machine adult
20 Weighing machine infant
21 Head Box

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 Annexure II

Emergency Obstetric Care Drugs Kit for District Hospital

Available
Sr.No. Drugs Remarks
(Yes/No)
1 Halothane BP
2 Atropine Injection
3 Thiopentone Injection
4 Bupivacaine Injection
5 Lignocaine Injection
6 Pentazocine Injection
7 Diazepam Injection
8 Dexmethsone Injection
9 Promethazine Injection
10 Nifedipine Capsules
11 Digoxin Tablets
12 Frusemide Tablets & Inj
13 Ampicillin Injection
14 Gentamycin Injection
15 Amoxycillin Capsules
16 Norfloxacin Tablets
17 Theophylline IP
18 Benzathine Penicillin Injection
19 Ergometrine Tablets
20 Magnesium Sulphate Injection
21 Ketamine Injection
22 Adrenaline Injection

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Other Drugs List

Available
Sr.No. Drugs Remarks
(Yes/No)
Analgesics/Antipyretics/Anti
A
Inflamatory
1 Tab. Aspirin 300mg
2 Tab. Paracetamol 500mg
3 Inj. Diclofenac sodium
4 Tab. Diclofenac sod
5 Tab. Dolonex DT 20mg
6 Tab. Ibuprofen
B Chemotherapeutics
7 Inj. Crystalline penicillin 5 lac unit
8 Inj. Fortified procaine pen 4 lac
9 Inj. Ampicillin 500mg
10. Inj. Cloxacillin
11 Inj.Gentamycin 40mg/2ml vial
12 Inj. Crystalline penicillin 10 lac unit
13 Cap. Ampicillin 250mg
14 Cap. Tetracycline 250mg
15 Tab. Trimethoprim + Sulphamethazolss
16 Tab. Ciprofloxacin 250mg
17 Tab. Ciprofloxacin 500mg
18 Inj. Ciprofloxacin 100ml
19 Tab. Erythromycin 250mg
20 Tab. Erythromycin 500mg
21 Syrup Cotrimoxazole 50ml
22 Syrup Ampicillin 125mg/5ml 60ml
23 Inj. Cefoperazone 1Gm (Desirable)
24 Inj. Cefotaxime 500mg
25 Tab. Norfloxacin 200mg
26 Inj Ceftriaxone
27 Diazepam Inj. IP
28 Inj. Cefotaxime
29 Inj. Cloxacillin
Dexamethasone Sodium Phosphate inj.
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IP
31 Aminophylline Inj. BP
32 Adrenaline Bitartrate Inj. IP
33 Ringer Lactate
34 Doxycycline Hydrochloride
Medicines and other consumables required for different National disease
control programmes
1 Tab. and syrup Chloroquine
2 Tab. Primaquine (2.5 mg and 7.5 mg)
3 Tab. DEC (Di Ethyle Carbamazine–only in
filaria endemic areas)
4 Anti leprosy drugs (MDT Blister Packs)
5 Anti-tuberculosis drugs
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6 Rapid Diagnostic Kits for Malaria under
National Vector Borne Disease Control
Programme

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