Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW
PHC/CHC (NON FRU) level Monitoring Checklist
Name of District: _______________
Catchment Population:
__________
Name of Block: _______________
Name of PHC/CHC: _________________
Total Villages: ________________
Distance from Dist HQ: __________
Date of last supervisory visit:__________
Date of visit: _____________
Name& designation of monitor:_____________________________
Names of staff not available on the day of visit and reason for
absence:_____________________________________________________________________________________________________________
Section I: Physical Infrastructure:
S.No
1.1
Health facility easily accessible from nearest
Yes
Y
No
N
1.2
road head
Functioning in Govt building
Y
N
1.3
Building in good condition
Y
N
1.4
Habitable Staff Quarters for MOs
Y
N
1.5
Habitable Staff Quarters for SNs
Y
N
1.6
Habitable Staff Quarters for other categories
Y
N
1.7
Electricity with functional power back up
Y
N
1.9
Running 24*7 water supply
Y
N
1.10
Clean Toilets separate for Male/Female
Y
N
1.11
Functional and clean labour Room
Y
N
1.12
Y
N
Y
N
1.14
Functional and clean toilet attached to labour
room
Functional New born care corner(functional
radiant warmer with neo-natal ambu bag)
Functional Newborn Stabilization Unit
Y
N
1.15
Clean wards
Y
N
1.16
Separate Male and Female wards (at least by
Partitions)
Availability of complaint/suggestion box
Y
N
Y
N
Availability of mechanisms for waste
management
Y
N
1.13
1.17
1.18
Infrastructure
Additional Remarks
Section II: Human resource:
S. no
2.1
2.2
2.3
2.4
2.5
Category
MO
SNs/ GNMs
ANM
LTs
Pharmacist
Numbers
Remarks if any
Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW
2.6
LHV/PHN
2.7
Others
Section III: Training Status of HR
S. no
Training
3.1
BeMOC
3.2
SBA
3.3
MTP/MVA
3.4
NSV
3.5
IMNCI
3.6
F- IMNCI
3.7
NSSK
3.8
Mini Lap
3.9
IUD
3.10
RTI/STI
3.11
Immunization and cold chain
3.12
Others
No. trained
Remarks if any
Yes
Y
No
N
Remarks
Y
Y
N
N
Y
N
Y
Y
Y
Y
N
N
N
N
Y
Y
N
N
Y
N
Y
Yes
Y
Y
Y
N
No
N
N
N
Section IV: Equipment
S. No
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
4.15
4.16
Equipment
Functional BP Instrument and
Stethoscope
Sterilised delivery sets
Functional neonatal, Paediatric and
Adult Resuscitation kit
Functional Weighing Machine (Adult and
infant/newborn)
Functional Needle Cutter
Functional Radiant Warmer
Functional Suction apparatus
Functional Facility for Oxygen
Administration
Functional Autoclave
Functional ILR
Functional Deep Freezer
Emergency Tray with emergency
injections
MVA/ EVA Equipment
Laboratory Equipment
Functional Microscope
Functional Hemoglobinometer
Functional Centrifuge,
Remarks
Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW
4.17
4.18
Functional Semi autoanalyzer
Reagents and Testing Kits
Y
Y
N
N
Section V: Essential Drugs and Supplies
S.No
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
Drugs
5.16
Vaccine Stock available
S.No
5.17
Yes
No
Remarks
Supplies
Y
N
Pregnancy testing kits
Y
N
Urine albumin and sugar testing kit
Y
N
OCPs
Y
N
EC pills
Y
N
IUCDs
Y
N
Sanitary napkins
Yes
No
Remarks
Essential Consumables
Y
N
Gloves, Mckintosh, Pads, bandages,
and gauze etc.
Note: For all drugs and consumables, availability of at least 2 month stock to be
observed and noted
5.18
5.19
5.20
5.21
5.22
S.No
5.23
EDL available and displayed
Computerised inventory management
IFA tablets
IFA tablets (blue)
IFA syrup with dispenser
Vit A syrup
ORS packets
Zinc tablets
Inj Magnesium Sulphate
Inj Oxytocin
Misoprostol tablets
Mifepristone tablets
Antibiotics
Labelled emergency tray
Drugs for hypertension, Diabetes,
common ailments e.g PCM, antiallergic drugs etc.
Yes
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
No
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
N
Remarks
Section VI: Other Services :
S.no
6.1
6.2
6.3
6.4
6.5
Lab tests being conducted for
Haemoglobin
CBC
Urine albumin and Sugar
Serum Bilirubin test
Blood Sugar
Yes
Y
Y
Y
Y
Y
No
N
N
N
N
N
Remarks
Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW
6.6
6.7
6.8
6.9
6.10
RPR (Rapid Plasma Reagin) test
Malaria (PS or RDT)
T.B (Sputum for AFB)
HIV (RDT)
Others
Y
Y
Y
Y
Y
N
N
N
N
N
Section VII: Service Delivery in last two quarters:
S.No
7.1
7.2
7.3
7.4
Service Utilization Parameter
OPD
IPD
Expected number of pregnancies
7.5
Percentage of women registered in
the first trimester
7.6
Percentage of ANC3 out of total
registered
7.7
Percentage of ANC4 out of total
registered
7.8
7.9
Total deliveries conducted
Number of obstetric complications
managed, pls specify type
7.10
No. of neonates initiated breast
feeding within one hour
Number of children screened for
Defects at birth under RBSK
7.11
Percentage of women registered in
the first trimester
7.12
RTI/STI Treated
7.13
No of admissions in NBSUs, if available
7.14
7.15
7.16
7.17
7.18
7.19
7.20
7.21
7.22
7.23
7.24
No. of sick children referred
No. of pregnant women referred
No. of IUCD Insertions
No. of Tubectomy
No. of Vasectomy
No. of Minilap
7.25
7.26
7.27
7.28
No. of children fully immunized
Measles coverage
No. of children given ORS + Zinc
No. of children given Vitamin A
No. of women who accepted post partum
FP services
No. of MTPs conducted
Maternal deaths, if any
Still births, if any
Neonatal deaths, if any
Q1
Q2
Remarks
Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW
7.29
Infant deaths, if any
Section VII a: Service delivery in post natal wards:
S.No
Parameters
Yes
No
7.1a
All mothers initiated breast
feeding within one hr of normal
delivery
Zero dose BCG, Hepatitis B and
OPV given
Counseling on IYCF done
Counseling on Family Planning
done
Mothers asked to stay for 48 hrs
JSY payment being given before
discharge
Y
N
Y
N
Y
Y
N
N
Y
Y
N
N
Y
N
Y
N
7.2a
7.3a
7.4a
7.5a
7.6a
7.7a
7.8a
7.9a
Mode of JSY payment (Cash/
bearer cheque/Account payee
cheque/Account Transfer)
Any expenditure incurred by
Mothers on travel, drugs or
diagnostics(Please give details)
Diet being provided free of
charge
Remarks
Section VIII: Quality parameter of the facility
Through probing questions and demonstrations assess does the staff nurses and ANMs know how to…
S.No
8.1
8.2
Essential knowledge/Skill Set
Manage high risk pregnancy
Provide essential newborn
care(thermoregulation,
Knowledge
Y
N
Y
N
Skills
Y N
Y N
Manage sick neonates and
infants
Correctly uses partograph
Correctly insert IUCD
Y
N
Y
N
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
breastfeeding and asepsis)
8.3
8.4
8.5
8.6
8.7
8.7
8.8
Correctly administer
vaccines
Alternate Vaccine Delivery
(AVD) system functional
Segregate waste in colour
coded bins
Adherence to IMEP protocols
Remarks
Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW
Section IX: Record Maintenance:
S. no
Record
9.1
9.2
9.3
OPD Register
IPD Register
ANC Register
9.4
PNC Register
9.5
Indoor bed head ticket
9.6
Line listing of severely anaemic pregnant
women
Labour room register
Partographs
OT Register
FP Register
Immunisation Register
Updated Microplan
9.7
9.8
9.9
9.10
9.11
9.12
9.13
9.14
9.15
9.16
9.17
9.18
Available,
Updated
and
correctly
filled
Available
but Not
maintain
ed
Not
Avai
lable
Remarks/Timeline
for completion
Drug Stock Register
Referral Registers (In and Out)
Payments under JSY
Untied funds expenditure (Check %
expenditure)
AMG expenditure (Check %
expenditure)
RKS expenditure (Check %
expenditure)
Section X: Referral linkages in last two quarters:
S. no
JSSK
10.1
10.2
Home to facility
Inter facility
Facility to Home (drop
back)
10.3
Mode of
No. of
No. of
No. of
Transport women
sick
children
(Specify transpor infants
1-6
Govt./ pvt)
ted
transpor years
during
ted
ANC/INC
/PNC
Free/Paid
Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW
Section XI: IEC Display:
S.No
Yes
Y
No
N
11.1
11.2
11.3
11.4
11.5
11.6
11.7
11.8
Material
Approach roads have directions to the
health facility
Citizen Charter
Timings of the Health Facility
List of services available
Essential Drug List
Protocol Posters
JSSK entitlements
Immunization Schedule
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
N
11.9
JSY entitlements
Y
N
11.10
Other related IEC material
Y
N
Remarks
Section XII: Additional/Support Services:
Sl. no
12.1
12.2
12.3
12.4
12.5
12.6
12.7
Services
Regular sterilisation of Labour room
(Check Records)
Functional laundry/washing services
Availability of dietary services
Appropriate drug storage facilities
Equipment maintenance and repair
mechanism
Grievance redressal mechanisms
Tally software implemented
Yes
Y
No
N
Y
Y
Y
Y
N
N
N
N
Y
Y
N
N
Remarks
Section XIII: Previous supervisory visits:
S. no
Name and Designation of the
supervisor
Place of posting of
Supervisor
Date of visit
13.1
13.2
13.3
13.4
13.5
Note: Ensure that necessary corrective measures are highlighted and if possible, action taken on the spot.
The Monthly report of monitoring visits and action points must be submitted to the appropriate authority for
uploading on State MoHFW website
___________________________________________________________________________________________
To be filled by monitor(s) at the end of activity
Key Findings
Actions Taken/Proposed
Person(s)
Responsible
Timeline
Monitoring Checklist for the PHC/CHC (Non FRU)- MoHFW