Inspection Format for Hospital/Nursing Home
1. General Information
a. Name of establishment:
:……………………………………
b. Phone No:
:…………………………………………
c. Address of establishment
:…………………………………………
d. Whether Establishment New/ Old
:…………………………………………
e. Name of the proprietor:
:………………………………………….
f. Address of the proprietor
: :…………………………………………
g. Nature of firm: Ownership/ Partnership/
:…………………………………………
Registered company/Voluntary Organisation/
Society/PSU
:…………………………………………
h. Empanelled Under JSY/RSBY/ EMRI 108
:…………………………………………..
2.Building
a. Type of Building- Own/ Rented/ Leased
:…………………………………………
b. Well connected with roads
:…………………………………………
3. OPD Area
a. In OPD, Proper signage, Name of Doctor,
Qualification, Speciality
With available services ,
timings and phone number
:…………………………………………
:…………………………………………
:…………………………………………
:…………………………………………
b. Space requirements: As Follows
Space requirements
Consultation room+ Waiting area+
Treatment
Minimum std(sq.ft)
Dimensions present
200
c. Disable Friendly ramp
:…………………………………………
d. Waiting room with adequate sitting arrangement
:…………………………………………
e. Provision of safe drinking water
:…………………………………………
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f. Ventilation
:…………………………………………
g. Lighting
:…………………………………………
h. Power backup
:…………………………………………
i. Toilets(Separate for male and Female)
:…………………………………………
j. General Hygiene and Cleanliness
:……………………………………
k. Fire Safety equipment
:…………………………………………
l. Provision for privacy of female patients
:………………………………………
m. Provision of safe drinking water
:.............................................................
4. Consultation Room
a. separate cabins for various disciplines.
:…………………………………………
b. doctor’s chair, table,
:…………………………………………
c. patients chair,
:…………………………………………
d. wash basin,
:…………………………………………
e. X Ray film view box
:…………………………………………
f. other set of tools as may be required for
:…………………………………………
different disciplines.
:…………………………………………
5. Emergency Kit
a. Ambu bag
:………………………………………
b. Oxygen Cylinder
:…………………………………………
c. IV infusion Set and IV fluid
:…………………… ……………………
d. Emergency Medicines
:…………………………………………
f. Suction Machine
:…………………………………………
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6. IPD Area
a. Space requirements: as follows
Item
Minimum floor space per bed in ward
Minimum distance between centre of two beds
Area Required
100 sq. ft. for one bed
andadditional60
square feet for every
additional bed in the
room
6. ft.
Minimum clearance between bed and wall
Minimum width of doors in the wall
6 inches
3 ft.
Remark
Minimum area to be provided for the bath & 36 sq. ft.
toilet
Number of urinals
1 per 6 bed
Number of toilets and baths
1 per 6 bed
Number of wash basins
Minimum area of operation theatre (sterile
zone)
Minimum area for instrument serialization
1 per 10 bed
300 sq feet
50 sq. ft.
Minimum area for scrubbing up(there should be 25 sq. ft.
proper zoning into protective, clean zone and
sterile zone
Labor room with Toilets
Minimum area for Doctor’s duty room
Nurses Station
Ward store
Trolley bay
Consulting room & examination room
IPD Contd……
140 sq. ft. + 20 sq. ft.
100 sq. ft.(with toilet)
100 sq. ft.(with toilet)
100 sq. ft.
30 sq. ft.
120 Sq. ft.
Wards
:………………………………………
:…………………………………………
c. Condition of linen:
:…………………………………………
d. Stool for Attendant
:…………………………………………
e. Bed Head Ticket
:…………………………………………
f. Records maintenance ( Registers Available )
:…………………………………………
g. PPEs used by staff
:…………………………………………
h. Oxygen Cylinder Present
:…………………………………………
i. Needle Cutter present
:…………………………………………
j. BMW Management
:…………………………………………
k. Disinfection of infected linen in 1% hypochlorite solution :…………………………………………
:…………………………………………
before sending to laundry
a. Condition of Beds
b. Condition of Mattress
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7.Operation Theatre
:……………………………………
Zoning in OT Complex
Items Available:-
a. Slipper stand
:…………………………………………
b. Clean slippers
:…………………………………………
c. Emergency Medicine tray
:…………………………………………
d. Drug trolley
:…………………………………………
e. Instrument Trolley
:…………………………………………
f. Hub cutter
:…………………………………………
g. Macintosh for OT tables
:…………………………………………
h. Cupboards for instruments
:…………………………………………
i. Bio Medical Waste Bins
:…………………………………………
j. Power back up
:…………………………………………
Equipments in The O.T
a. Boyles Apparatus
:…………………………………………
b. Multi-Para Monitor
:…………………………………………
c. Suction machine(electric/ foot operated)
:…………………………………………
d. Oxygen Cylinder with Mask
:…………………………………………
e. Nitrous Oxide cylinder
:…………………………………………
f.
Shadow less lamps
:…………………………………………
g. Fumigation Record
:…………………………………………
h. Entries in the records complete
:…………………………………………
i.
Consent form
:…………………………………………
j.
Scrub Area present
:…………………………………………
k. Elbow Operated taps present
:…………………………………………
l.
:…………………………………………
Tiling of the Operation theatre
m. Autoclave machine available
:…………………………………………
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n. Autoclave machine working
:…………………………………………
o. Pressure Gauze of Autoclave Working
:…………………………………………
p. CSSD
:…………………………………………
q. Bilogical Indicator used for Autoclave (signalac tape) :…………………………………………
r.
Swab culture from OT examined and
:…………………………………………
records maintained
:…………………………………………
BMW Management:
:…………………………………………
8. Labor Room
a. Pre Partum Room present
:……………………………………
b. Post Partum Room present
:…………………………………………
c. Labor table with steps
:…………………………………………
New Born Baby Corner
a. Radiant Warmer
:………………………………………
b. Newborn Resuscitation kit
:…………………………………………
c. Laryngoscope
:…………………………………………
d. Mucus Extractor
:…………………………………………
e. Weighing machine
:…………………………………………
Trays
a. Emergency Medicine Tray
:…………………………………………
b. Baby Tray
:…………………………………………
c. Episiotomy Tray-
:…………………………………………
d. MVA Tray-
:…………………………………………
e. Delivery Tray
:…………………………………………
f. Medicine Tray
:…………………………………………
Others
a. Curtains between two Labor Table Present
:…………………………………………
b. Delivery Kits available
:…………………………………………
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c. Tiling of the Labor room
:…………………………………………
d. Protocols for NBCC Displayed
:…………………………………………
e. Protocols for Hypothermia Management Displayed
:…………………………………………
f. Running Tap Water Available
:…………………………………………
g. Provision of warm water
:…………………………………………
h. 24x 7 / On call Gynaecologist Available
:…………………………………………
i. Trained nurse to assist during delivery Present
:…………………………………………
j. Adequate Power back up Present
:…………………………………………
Minimum equipments required for labour room
a. Foetal monitor (Doppler or cardiotocograph)
:…………………………………………
b. One suction machine / foot suction machine
:…………………………………………
c. B.P. Instrument
:…………………………………………
d. Thermometer
:…………………………………………
e. Foetoscope -
:…………………………………………
f. oxygen cylinder
:…………………………………………
g. catheter, and nebulizers
:…………………………………………
h. Dressing trolley.
:…………………………………………
i. Instruments & equipments required for Emergency
:…………………………………………
j. obstetric care. ( LSCS, Obstetric hysterectomy, Forceps, ):…………………………………………
k. Defibrillator
:…………………………………………
l. Fire fighting equipment
:…………………………………………
9. Diagnostics
a. X-ray
:…………………………………………
b. USG
:…………………………………………
c. CT- Scan
:…………………………………………
d. MRI- Scan
:…………………………………………
e. Basic Pathological Tests
:…………………………………………
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f. Diagnostics As per the prescribed Standards
:…………………………………………
10. Human Resource
a. (Doctors)
Degree from recognized university/institute
and registration under Council recognized by
the Chhattisgarh Sate Government,
for the particular discipline (Allopathy/Ayush):
:…………………………………………
:…………………………………………
:…………………………………………
:…………………………………………
(Attach Separate sheet if required )
Specialty / Discipline
Desirable Qualifications
Super Specialist
DNB/MCH/DM/ Post PG Diploma/ Fellowship
General Surgeon
MS/DNB, (General Surgery)
Physician
MD/DNB, (General Medicine)
Obstetrician & Gynaecologist
DGO (OBG)/MS/DNB/MD
Paediatrics
DCH/MD(Paediatrics)/DNB
Orthopaedics
MS/DNB/D. ORTH
ENT Specialist
MS/DLO
Anaesthetist
MD(Anaesthesia)/DNB/DA
Eye surgeon
MD/MS/DOMS/DNB/(Ophthalmology)
Dental Surgeon
BDS
Pathologist
MD/DNB/DCP
Radiologist
MD/DNB/DMRE/DMRD/DMR
Psychiatrist
MD/DPM/DNB
Dermatologist
MD/DNB/Diploma
General Practitioner (allopathy)
MBBS/ or any other degree in allopathic
medicine
General practitioner (ayush)
BAMS/BHMS/ BUMS/Siddha/Yoga
Specialist of AYUSH
Post Graduate in AYUSH
Category of Staff
For How many Patients
Number to
be provided
RMO/GDMO
20 beds or its part
1
Nurses and Midwife
20 beds or its part
1
General Duty attendant
20 beds or its part
1
Sweeper
10 beds or its part
*This is on 8 hourly basis(per shift)
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1
b.
:……………………………………
:………………………………………
No of Paramedical Staff
(Attach Separate Sheet)
12. Biomedical Waste Management
a. Clearance from Pollution Control board
:…………………………………………
b. Availability of Colour coded Bins
:…………………………………………
c. Disposal- Outsourced /Within facility
:…………………………………………
d. If within the facility
:…………………………………………
e. Deep Pit or and Sharp Pit
:…………………………………………
13. Registers
a. OPD and Stock of life sving Drugs
:…………………………………………
b. Birth and Death Register
:…………………………………………
c. Labor room Register
:…………………………………………
d. IPD register
:…………………………………………
e. JSY payment (if empanelled)
:…………………………………………
f. PCPNDT Register
:…………………………………………
g. Stock Registers
:…………………………………………
h. USG Register
:…………………………………………
i. Radiology and Imaging register
:…………………………………………
j. Lab register
:…………………………………………
k. MTP Register
:…………………………………………
l. OT register
:…………………………………………
m. MLC register
:…………………………………………
n. Register for National Programmes
:…………………………………………
o. Complaint register
:…………………………………………
Note: Apart from above, any other defined, relevant Standards, mentioned in the Chattishgarh
Upcharyagriha Tatha Rogopchar Sambandhi Sthapanaye Anugyapan Niyam, 2013, has to be
added in this Inspection format.
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Member Inspection Team
Member Inspection Team
Member Inspection Team
District………………
District……………………
District……………………
Opinion :-
This is Certified that the Inspection team has examined Clinical establishment
……………………………………… Address……………………………….. on ……………………….. and
found various parameters as per the standards mentioned in the Upcharyagriha Tatha Rogopchar Sambandhi
Sthapanaye Anugyapan Niyam, 2013. This was put before the District Committee. On behalf of the
committee, I here by recommend/do not recommend for Issuance of registration/ license to the
aforesaid clinical establishment.
Place ……………
Date…………….
Chief Medical & Health Officer
District ………………………..
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