INSPECTION FORM OF RURAL HEALTH CENTRE - PHSRP - Punjab

INSPECTION FORM OF RURAL HEALTH CENTRE
HEALTH DEPARTMENT (GOVERNMENT OF THE PUNJAB)
A ‐ RURAL HEALTH CENTRE INFORMATION
DHIS Code:
Name of RHC: __________________________________
Mauza: __________________________ UC Name: _______________________________ UC No. ___________________ NA
No. _________ PP. No. _________ District: _________________________ Tehsil: _____________________________ Name
of Incharge of the facility: __________________________________ Designation: ______________________ Mobile No.:
_______________________ RHC’s Phone (with code): _______________________________________ Name of DDOH
_____________________________________________ Reference No. ___________________________ Date & Time of
arrival for inspection: _____/_______/______ Time: Hours __________ Minutes _______
am / pm
B ‐ CLEANLINESS AND GENERAL
OUTLOOK OF THE FACILITY
(tick relevant column)
C ‐ DISPLAYS
(tick relevant column)
Sr. No Location Good Average Poor ITEMS Yes No
1 Boundary Wall Signboards/Direction Board displayed
2 Lawns
1) Organogram
3 Waiting Area Display in 2) Map of Union council showing all localities
4 Building the MO/ 3) Statistics of the Union Council and the RHC
5 Labour Room Incharge 4) Tour Programme of ‘outreach team’
6 Wards office: 5) Duty Roster of Doctors
7 Toilets 6) Duty Roster of Nurses
8 Operation Theatre 7) Others
D ‐ AVAILBILITY OF UTILITIES
(tick relevant column)
E ‐ HOSPITAL WASTE MANAGEMENT
(tick relevant column)
Sr. No Name of Utility Not
Available Sr. No Mode Yes No
Available Functional Non
1 Hospital Waste Segregated as per
Functional
guidelines
1 Electricity 2 Hospital Waste Lying Open
2 Telephone 3
(a) Incinerator
3 Water supply System Burnt by: (b) Other means
4 Sui Gas 4 Buried
5 Sewerage System 5 Carried away by municipality
6 Other 6 Any other (Please state)
F ‐ PURCHI FEES (give amount)
Fee Deposited during the current financial year till the last calendar month: (Rs.) ________________________________
Purchi fee being charged @ Rs. ____________________________ per patient.
G ‐ PATIENTS TREATED IN LAST CALENDAR MONTH (give numbers)
Sr. No Cases Numbers Sr. No. Cases Numbers
1. OPD Cases 11. Ante‐Natal Visits
2. Percentage of pervious day OPD Cases
12. Family Planning Consultations
registered with NIC No.
3. Laboratory Tests 13. TB Cases Diagnosed Positive
4. X‐Rays 14. TB Patients under Treatment
5. Dental Treatment 15. Hepatitis “B” Vaccinations Done (3 doses)
6. Minor Surgeries 16. Malaria Diagnosis Tests Conducted
7. Deliveries at RHC 17. Blood Screening Tests for Transfusion
8. Children vaccinated at RHC 18. Total Indoor Patients
9. Children vaccinated outside RHC 19. Total patients days of admitted patients
10. TB Test Conducted 20 No. of patients transported via ambulance
H ‐ DOCTORS (give numbers)
Sanctioned Posts Filled Posts On Duty (Morning) Present (Morning)
Details regarding absence of doctors. (Do not write anything if a doctor is present.)
Sr. No Designation Name of Doctors Type of Absence on the monitoring day.
(tick only one box)
Days of absence during last
three calendar months
1 SMO UA SL OD St. L LC UA Other Types
2 MO
3 WMO
4 Dental Surgeon
Unauthorized absence (UA), Sanctioned leave (SL), On official duty outside the BHY (OD), Short leave (St.L), Late Comer (LC).

I ‐ PARAMEDICS (OTHER THAN DOCTORS)
PARAMEDICS
INCLUDES:
Charge Nurse, Dispenser, Dresser, Dental Assistant, Operation Theatre Assistant, Medical Assistant,
Anesthesia Assistant, Medical Technician, Health Technician
Sr. No Staff Category Sanctioned Filled Posts Present
1 Nurses
2 Other paramedics (Other than nurses)
Details regarding absence of Paramedics. (Do not write anything if staff is present.)
Sr. No
1
2
3
Designation
Name of Staff
Type of Absence on the monitoring day.
(tick only one box)
Days of absence during last
three calendar months
UA SL OD St. L LC UA Other Types
J ‐ ALTERNATIVE MEDICATION STAFF
ALTERNATIVE MEDICATION
STAFF INCLUDES:
Homeo Doctor, Hakeem/Tabeeb, Dawa Saaz, Homeo Dispenser, Dawa Kobe
Sanctioned Posts Filled Posts Present
Details regarding absence of alternative medication staff. (Do not write anything if staff is present.)
Sr. No
1
2
3
Designation
Name of Staff
Type of Absence on the monitoring day.
(tick only one box)
Days of absence during last
three calendar months
UA SL OD St. L LC UA Other Types
K ‐ PREVENTIVE / OUTREACH STAFF
PREVENTIVE / OUTREACH STAFF
INCLUDES:
LHV, RHI< Midwife, Dai, Vaccinator, CDC Supervisor, Sanitary Patrol, Sanitary Inspector,
Sanitary Worker
Sanctioned Posts Filled Posts Present
Sr. No
1
2
3
Details regarding absence of Preventive / outreach staff.(Do not write anything if staff is present.)
Designation
Name of Staff
Type of Absence on the monitoring day.
(tick only one box)
Days of absence during last
three calendar months
UA SL OD St. L LC UA Other Types
L ‐ TECHNICAL STAFF
TECHNICAL STAFF INCLUDES:
Dental Technician, Lab. Technician, X‐Ray Technician, X‐Ray Assistant, Lab. Assistant, Microscopist,
Radiographer
Sanctioned Posts Filled Posts On Duty (Morning) Present (Morning)
Sr. No
1
2
3
Designation
Detail regarding absence of Technical Staff. (Do not write anything if staff is present).
Name of Staff
Type of Absence on the monitoring day.
(tick only one box)
Days of absence during last
three calendar months
UA SL OD St. L LC UA Other Types

M ‐ ADMIN / SUPPORT STAFF
ADMIN / SUPPORT INCLUDES:
Accountant, Senior Clerk, Junior Clerk, Computer Operator, Driver, Cook, Store Keeper, Naib Qasid,
Tubewell Operator, Ward Servant, Water Carrier, Chowkidar, Mali, Peon, Sweeper
Sanctioned Posts Filled Posts On Duty (Morning) Present (Morning)
Detail regarding absence of Admin / Support Staff. (Do not write anything if staff is present).
Sr. No
1
2
3
Designation
Name of Staff
Type of Absence on the monitoring day.
(tick only one box)
Days of absence during last
three calendar months
UA SL OD St. L LC UA Other Types
N ‐ VACANT POSTS (please write full name of post)
Sr. No Name of Post Number of Vacant
Post
Sr. No Name of Post Number of
Vacant Post
1 7
2 8
3 9
4 10
5 11
6 12
O ‐ INSPECTION OF THE FACILITY BY DISTRICT GOVERNMENT OFFICERS
From Inspection Register. (give number / dates)
Sr. No Inspecting Officer DDO (H) DO (H) EDO (H) DCO or his
Representative
1 Number of inspections made during
the last six calendar months as per
record of inspection book
2 Date of Last Inspection
Sr.
No.
P ‐ AVAILABILITY OF MEDICINES (give numbers of tablets / bottles etc.)
(Medicines physically available on the date of visit in the stock & as per Medicines Stock Register)
Medicines
1 Cap. Amoxicillin
2 Syp. Amoxicillin
3 Tab. Cotrimoxazole
4 Syp. Cotrimoxazole
5 Any Other antibiotic Tablet
6 Tab. Metronidazole
7 Syp. Metronidazole
8 Inj. Ampicillin
9 Tab Diclofenac
10 Inj. Diclofenac
11 Syrup Paracetamol
12 Chloroquine Tab
13 Syrup Salbutamol
14 Syp. Antihelminthic
15 I/V Infusions
16 Inj. Dexamethasone
17 Iron/Folic Tab.
18 ORS (Packets)
19 Oral Contraceptive Pills
20 Anti‐Histamine Tab.
21 Inj. Anti‐Histamine
22 Anti‐Tuberculosis Drugs
23 Tetanus Toxoid Injections
24 Inj. Atropin
25 Inj. Adrenaline
26 Ant acid Tab.
27 Bandages
28 Antiseptic Solution (Bottles)
29 Disposable Syringes
Yes
Available
No
Balance as on
1 st of last
month (1)
Received Since
1 st of last
month (2)
Total
3=(1+2)
Consumed
since 1 st of last
month till
today (4)
Balance as per
register
5=(3‐4)

Q ‐ PUBLIC OPINION (please give number of persons in the relevant columns.)
Views
1) Presence of Doctors
2) Attitude of doctors towards patients
3) Waiting Time
4) Free availability of medicines
5) Vaccinators outreach
6) Vaccination at RHC
Note:
Number of persons
contacted in the
catchment area
Satisfactory
Names and Contact Numbers of at least two persons interviewed during the visit
PUBLIC OPINION
Unsatisfactory
Average
No Response
Sr. No. Name Address Contact Number
R ‐ INDOOR PATIENTS DEPARTMENT
Functional
Non‐Functional
Total Number of
admitted patients
Male
Female
Children
(under 12 Years)
Sr.
No.
S ‐ DEVELOPMENT SCHEMES / PROVISION OF MISSING FACILITIES (TICK THE COLUMN)
Missing facilities Funds provided by Status of work Quality Observations
PHSRP District
Govt.
Not
Started
Halted % Completed
(Give number)
Poor Avg. Good (Use extra page if
required)
1 RHC Building
2 Residences
3 Boundary wall
4 Electricity
5 Drinking Water
6 Latrine/Toilet
7 Furniture Sui Gas
8 Sewerage
9 Other
10
Sr. No.
Name of Equipment
1 X‐Ray Machine
2 Dental Unit
3 Dental X‐ray Machine
4 ECG Machine
5 Hot Air Oven
6 Auto Clave
7 Sterilizer
8 Nebulizer
9 Ultrasound Machine
10 O.T. ceiling Light
11 O.T. Table
12 General Surgery Instrument Set
13 Obstetric Instrument Set
14 Fetal Heart Detector
15 Oxygen Cylinder with flow meters
16 Lab Equipment
17 Ambu Bag
18 Bulb Sucker
19 Baby Warmer
Sr. No.
Name of Equipment
1 Ambulance
2 Air‐conditioner for Operation Theatre
3 Computer
4 Printer
5 UPS
6 Electric Generator
7 General Store (Liren, Bedside lockers etc.)
T (i) – Medical Equipment (give numbers)
Available
Functional
If Non‐Functional
Repairable Unserviceable
T (ii) – NON MEDICAL Equipment (give numbers)
Available
Functional
If Non‐Functional
Repairable Unserviceable
Remarks
Remarks

U– RESIDENCES (give numbers)
Sr. No.
1
2
3
Name of Post
Residence
Available
Residence
Occupied
(Yes/No)
Physical Status of Residence
Reside able Not reside able
Remarks
V– EMERGENCY
Sr.
No.
Emergency Yes No
1 Emergency Room Properly equipped
2 Medicines available in Emergency Room
3 Medicines supplied free of cost during first 24 hrs.
4 Emergency staff available as per roster
W– SERVICES
Services Yes No
AIDS & HEPATTIS CONTROL
1 100% Blood screening for HIV, HBV & HCV
2 Syringe cutters available
3 Syringe cutters being used
EPI
4 Cold chain intact
5 Temperature chart maintained
6 All vaccines available at EPI center
NATIONAL PROGAM FOR FP/PHC
7 LHW monthly meeting held
8 LHW monthly meeting compiled
9 Monthly supplies / medicines replenished
MCH
10 Labour Room Functional equipment available
11 Operation Theater for Gynae / Obstetrics functional
12 Family Planning services being provided
X– REFERRALS
Sr. No. Indicator Yes Number
1 Patients referred to the facilities
2 Patients referred from the facilities
Y– MONTHLY PERFORMANCE
Sr. No. Indicator Monthly Target Performance
1 Daily OPD attendance
2 Children given full Immunization coverage
3 Delivery coverage at facility
Z– GENERAL REMARKS
Time of Departure from the facility: Hours______Minutes____________am
/ pm
Certified that this Rural Health Centre was inspected today by the undersigned and the information stated
above is as per facts and record.
____________________ ________________________________ ______________________
Signature of DDOH/MEA Signatures & Stamp of MO/Incharge Signatures of DMO/EDO(H)

EVENING SHIFT
Date of Visit:______/______/________
Sr.
No.
Designation
1 Doctor
2 Nurses
On duty in evening shift
(give numbers)
Present in
evening shift
(give numbers)
Time of Arrival: Hours___________Minutes__________
3 Other Paramedics
4 Technical Staff
Time of Departure: Hours_________Minutes_________
5 Admn/Support Staff
DETAILS OF ABSENCE
(Do not write anything if staff is present.)
Sr. No. Designation Name Type of Absence on the monitoring day.
(tick only one box)
Days of absence during
last three calendar
months
UA SL OD St. L LC UA Other Types
1
2
3
4
5
6
______________ ________________________________ _________________
Signature of DDOH/MEA Signatures & Stamp of MO/Incharge Signatures of DMO/EDOH
NIGHT SHIFT
Date of Visit:______/______/________
Sr.
No.
Designation
1 Doctor
On Call as per duty
roster (give numbers)
Available on
Call (give
numbers)
Sr.
No.
Designation
1 Nurses
2 Other Paramedics
3 Technical Staff
4 Admn/Support Staff
On duty in evening shift
(give numbers)
Present in
evening shift
(give numbers)
Time of Arrival: Hours___________Minutes__________
Time of Departure: Hours_________Minutes_________
DETAILS OF ABSENCE
(Do not write anything if staff is present.)
Sr. No. Designation Name Type of Absence on the monitoring
day. (tick only one box)
Days of absence during last
three calendar months
UA SL OD St. L LC UA Other Types
1
2
3
4
5
6
______________ ________________________________ _________________
Signature of DDOH/MEA Signatures & Stamp of MO/Incharge Signatures of DMO/EDOH