BHU/RHC New Inspection Proforma - PHSRP - Punjab
BHU/RHC New Inspection Proforma - PHSRP - Punjab
BHU/RHC New Inspection Proforma - PHSRP - Punjab
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
INSPECTION FORM OF BASIC HEALTH UNIT / RURAL HEALTH CENTRE<br />
HEALTH DEPARTMENT (GOVERNMENT OF THE PUNJAB)<br />
A – INFORMATION OF HEALTH FACILITY<br />
Facility Code:<br />
Name of <strong>BHU</strong>/<strong>RHC</strong>: __________________________________________<br />
Managed by: i) PRSP ii) Dist. Govt. (please tick only one option)<br />
Mauza: __________________________ UC Name: _______________________________ UC No. ___________________<br />
NA No. _________ PP. No. _________ District: _________________________ Tehsil: _____________________________<br />
Name of incharge of the facility: __________________________________ Designation: ______________________<br />
Mobile No.: ____________________________ Phone (with code): _______________________________________<br />
Name of Visiting Officer with Designation: _______________________________________________________________<br />
Date & Time of arrival for inspection: _____/_______/______ Time: Hours __________ Minutes _______ am / pm<br />
B ‐ CLEANLINESS AND GENERAL<br />
OUTLOOK OF THE FACILITY<br />
(tick relevant column)<br />
C ‐ DISPLAYS<br />
(tick relevant column)<br />
Sr. No Location Good Average Poor ITEMS Yes No<br />
1 Boundary Wall Signboards/Direction Board displayed<br />
2 Lawns<br />
1) Organogram<br />
3 Waiting Area Display in 2) Map of Union council showing all<br />
4 Building<br />
the MO/ localities<br />
5 Labour Room Incharge 3) Statistics of the Union Council and<br />
6 Wards<br />
office: the <strong>BHU</strong>/<strong>RHC</strong><br />
7 Toilets 4) Tour Programme of ‘outreach team’<br />
D ‐ AVAILBILITY OF UTILITIES<br />
(tick relevant column)<br />
E ‐ DISPOSAL OF HOSPITAL WASTE<br />
(tick relevant column)<br />
Sr. No Name of Utility Not<br />
Available Sr. No Mode Yes No<br />
Available Functional Non<br />
Functional<br />
1 Hospital Waste Segregated as per<br />
guidelines<br />
1 Electricity 2 Hospital Waste Lying Open<br />
2 Telephone 3<br />
(a) Incinerator<br />
3 Water supply System Burnt by: (b) Other means<br />
4 Sui Gas 4 Buried<br />
5 Sewerage System 5 Carried away by municipality<br />
6 Other 6 Any other (Please state)<br />
F ‐ PURCHI FEES (give amount)<br />
Fee Deposited during the current financial year till the last calendar month: (Rs.) ________________________________<br />
Purchi fee being charged @ Rs. ____________________________ per patient.<br />
G ‐ PATIENTS TREATED IN LAST CALENDAR MONTH (give numbers)<br />
Sr. No Cases Numbers Sr. No. Cases Numbers<br />
1 OPD Cases 9 Hepatitis “B” Vaccination Done<br />
2 Percentage of pervious day OPD<br />
10 Antenatal Cases Checked<br />
Cases registered with NIC No.<br />
3 Deliveries at <strong>BHU</strong> 11 Family Planning Visits<br />
4 PCD slides prepared 12 Referrals by LHW<br />
5 Referrals to other hospitals For <strong>RHC</strong>s only<br />
6 Children vaccinated at <strong>BHU</strong> 13 Total Indoor patients<br />
7 Children vaccinated outside <strong>BHU</strong> 14 Total patients days of admitted patients<br />
8 TB Patients under Treatment 15 Numbers of patients transported via ambulance<br />
H‐ SCHOOL HEALTH PROGRAM (FOR <strong>BHU</strong>s ONLY)<br />
S. No. Indicator (Last Calendar Month) Numbers<br />
1 Students referred by SH&NS<br />
2 Student treated at <strong>BHU</strong> referred by SH&NS<br />
3. School visited by SH&NS<br />
4. Tour program approved and displayed Yes / No<br />
I – ABSENCE OF DOCTORS/OTHER STAFF<br />
Sr. No Designation Name of Doctors/Other staff Type of Absence on the monitoring day.<br />
(tick only one box)<br />
Days of absence during last<br />
three calendar months<br />
UA SL OD St. L LC UA Other Types<br />
1<br />
Unauthorized absence (UA), Sanctioned leave (SL), On official duty outside the BHY (OD), Short leave (St.L), Late Comer (LC).
J‐ (i) VACANCY POSITION OF THE TOTAL STAFF (FOR <strong>BHU</strong>s)<br />
Please Tick<br />
Sr.<br />
No<br />
Name of Post Sanctioned Filled Vacant<br />
1 MO/ WMO<br />
2 School Health & Nutrition Supervisor<br />
3 Computer Operator<br />
4 Medical Technician / Health Technician / Medical Assistant<br />
5 Lady Health Visitor<br />
6 Sanitary Inspector<br />
7 Dispenser<br />
8 Midwife<br />
9 Naib Qasid<br />
10 Chowkidar<br />
11 Sanitary Worker<br />
12 Any Other (With Designation)<br />
J‐ (ii) VACANCY POSITION OF THE TOTAL STAFF (FOR <strong>RHC</strong>s)<br />
1 SMO / SWMO<br />
2 Medical Officer<br />
3 Women Medical Officer<br />
4 Dental Surgeon<br />
5 Charge Nurse<br />
6 Computer Operator<br />
7 Dental Technician<br />
8 Laboratory Technician<br />
9 Lady Health Visitor<br />
10 Senior Clerk<br />
11 Dresser<br />
12 Operation Theater Assistant<br />
13 Anaesthesia Assistant<br />
14 X‐Ray Assistant<br />
15 Dispenser<br />
16 Laboratory Assistant<br />
17 Midwife<br />
18 Driver<br />
19 Tubewell Operator<br />
20 Ward Servant (M/F)<br />
21 Naib Qasid<br />
22 Water Carrier<br />
23 Chowkidar<br />
24 Mali<br />
25 Sanitary Worker<br />
Sr.<br />
No.<br />
1 Cap. Amoxicillin<br />
2 Syp. Amoxicillin<br />
3 Tab. Cotrimoxazole<br />
4 Syp. Cotrimoxazole<br />
5 Tab. Metronidazole<br />
6 Syp. Metronidazole<br />
7 Inj. Ampicillin<br />
8 Tab Diclofenac<br />
9 Inj. Diclofenac<br />
K ‐ AVAILABILITY OF MEDICINES (give numbers of tablets / bottles etc.)<br />
(Medicines physically available on the date of visit in the stock & as per Medicines Stock Register)<br />
Medicines<br />
Consumption during<br />
previous month<br />
Balance at the time<br />
of visit<br />
Actions required (Re‐distribution,<br />
replenishment any other)
10 Syrup Paracetamol<br />
11 Chloroquine Tab<br />
12 Syrup Salbutamol<br />
13 Syp. Antihelminthic<br />
14 I/V Infusions<br />
15 Inj. Dexamethasone<br />
16 Iron/Folic Tab.<br />
17 ORS (Packets)<br />
18 Oral Contraceptive Pills<br />
19 Anti‐Histamine Tab.<br />
20 Inj. Anti‐Histamine<br />
21 Anti‐Tuberculosis Drugs<br />
22 Tetanus Toxoid Injections<br />
23 Inj. Atropin<br />
24 Inj. Adrenaline<br />
25 Ant acid Tab.<br />
26 Bandages<br />
27 Antiseptic Solution (Bottles)<br />
28 Disposable Syringes<br />
Note: Three or four drugs may be counted in detail.<br />
L‐ INSPECTION OF THE FACILITY BY DISTRICT GOVERNMENT OFFICERS<br />
From <strong>Inspection</strong> Register. (give number / dates)<br />
Sr. No. Inspecting Officer DDO (H) DO (H) EDO (H) DCO or his<br />
Representative<br />
1 Number of inspections made<br />
during the last six months as<br />
per record of inspection book<br />
2 Date of Last <strong>Inspection</strong><br />
PRSP<br />
Representative (in<br />
PRSP Dist. Only)<br />
M‐ PUBLIC OPINION (please give number of persons in the relevant columns.)<br />
Views<br />
1) Presence of Doctors<br />
Number of persons<br />
contacted in the<br />
catchment area<br />
Satisfactory<br />
PUBLIC OPINION<br />
Unsatisfactory<br />
Average<br />
No Response<br />
2) Attitude of doctors towards patients<br />
3) Waiting Time<br />
4) Free availability of medicines<br />
5) Vaccinators outreach<br />
6) Vaccination at Health Facility<br />
Note:<br />
Names and Contact Numbers of at least two persons interviewed during the visit<br />
Sr. No. Name Address Contact Number<br />
N ‐ DEVELOPMENT SCHEMES / PROVISION OF MISSING FACILITIES (tick the column)<br />
Sr. No Missing Facilities<br />
1 Building<br />
2 Residences<br />
3 Boundary wall<br />
4 Electricity<br />
5 Drinking Water<br />
6 Latrine/Toilet<br />
7 Furniture Sui Gas<br />
8 Sewerage<br />
9 Other<br />
Schemes Status of Work Quality Future<br />
NLC District Govt. Date of<br />
Completion<br />
Work in<br />
Progress.<br />
Poor Avg. Good Requirements
O (i)‐ MEDICAL EQUIPMENT (give numbers)<br />
Sr.<br />
No.<br />
Name of Item Available Functional<br />
1 Delivery Table<br />
2 Delivery Light<br />
3 Hospital Beds<br />
4 Sucker<br />
5 Oxygen Cylinders<br />
6 Autoclave<br />
7 Glucometer<br />
8 Safe Delivery Kit<br />
9 Emergency tray with life saving medicines<br />
10 Ambu Bag<br />
11 Bulb Sucker<br />
12 Baby Warmer<br />
For <strong>RHC</strong>s only<br />
13 X‐Ray<br />
14 Dental Unit<br />
15 Dental X‐Ray<br />
16 Ultrasound<br />
17 Fetal Heart Detector<br />
18 ECG Machine<br />
Repairable<br />
If Non‐Functional<br />
Unserviceable<br />
Remarks<br />
O (ii) – NON‐MEDICAL EQUIPMENT (give numbers)<br />
Sr. No. Name of Item Available Functional<br />
1 Computer<br />
2 Printer<br />
3 UPS<br />
For <strong>RHC</strong>s only<br />
4 Ambulance<br />
5 Air‐Conditioner for Operation theatre<br />
6 Generator<br />
If Non‐Functional<br />
Repairable Unserviceable<br />
Remarks<br />
P – RESIDENCES (give numbers)<br />
Sr. No.<br />
1<br />
Name of Post<br />
Residence<br />
Available<br />
Residence<br />
Occupied<br />
(Yes/No)<br />
Physical Status of Residence<br />
Reside able Not reside able<br />
Remarks<br />
2<br />
3<br />
4<br />
5<br />
6<br />
Q ‐ SERVICES<br />
Sr. No YES NO<br />
AIDS & HEPATITIS CONTROL<br />
1 Syringe cutters available<br />
2 Syringe cutters being used<br />
EPI<br />
3 Cold Chain intact<br />
4 All vaccines available at EPI Center<br />
NATIONAL PROGRAM FOR FP & PHC<br />
5 LHW monthly meeting held<br />
6 LHW monthly meeting report completed
7 Monthly supplies / medicines replenished<br />
MCH<br />
8 Labour Room equipment available<br />
9 Labour Room equipment functional<br />
10 Family planning services being provided<br />
LOGISTICS<br />
11 General supplies available (Linens, bedside lockers, etc.)<br />
EMERGENCY (FOR <strong>RHC</strong>s ONLY)<br />
1 Emergency room properly equipped<br />
2 Medicines available for Emergency<br />
3 Medicines supplied free of cost during first twenty four hours<br />
4 Emergency staff available as per duty roster<br />
R– GENERAL REMARKS<br />
1. Problems Identified during previous visit<br />
2. Actions taken on Previous report<br />
3. Observations of current visit<br />
Time of Departure from the facility: Hours ________ Minutes ________ am / pm<br />
Certified that this Basic Health Unit / Rural Health Centre was inspected today by the undersigned and the<br />
information stated above is as per facts and record.<br />
_____________________________________<br />
Signature of Visiting Officer with Designation<br />
Note: Extra sheets may be utilized for remarks / explanation of any entry.
Change language