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Health Facility Monitoring Performa

This document is a monitoring form for a health facility in Pakistan. It collects information in three sections: cleanliness and infrastructure of the facility, availability of emergency medications and supplies, and infection prevention and control protocols. The form records details like staff attendance, condition of the building, availability of drugs, medical equipment, and emergency medications. It also notes infection control measures such as hand washing stations, personal protective equipment, waste management, and water supply. The purpose is to assess and monitor key aspects of service delivery and safety at the health center.

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Amer
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225 views4 pages

Health Facility Monitoring Performa

This document is a monitoring form for a health facility in Pakistan. It collects information in three sections: cleanliness and infrastructure of the facility, availability of emergency medications and supplies, and infection prevention and control protocols. The form records details like staff attendance, condition of the building, availability of drugs, medical equipment, and emergency medications. It also notes infection control measures such as hand washing stations, personal protective equipment, waste management, and water supply. The purpose is to assess and monitor key aspects of service delivery and safety at the health center.

Uploaded by

Amer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GOVERNMENT OF PAKISTAN

M/O NATIONAL HEALTH SERVICES, REGULATIONS & COORDINATION


DISTRICT HEALTH OFFICE
ISLAMABAD
****
PERFORMA FOR MONITORING VISIT TO HEALTH FACILITY

Name of Health Facility:

Name of Centre:

Attendance of Staff: Total No: Present: On leave: Absent:

Date of Inspection: Time in of Inspection: Time Out of Inspection:

A: CLEANLINESS AND GENERAL OUTLOOK OF HEALTH FACILITY

Sr.# Description Good Average Poor Non-Existent


1. Cleanliness

2. Direction Board

3. Boundary Wall

4. Building

5. Offices

6. Waiting Area

7. Labour Room

8. Laboratory

9. Lawn

10. Hand Wash Facility

11. Toilet

12. Electricity

13. Telephone

14. Sui Gas

15. Water Supply

16. Sewerage/Waste Management

(P.T.O)

1
Sr.# Items Yes No
1. Internal Sign/Direction Boards
2. Map of respective Union Council (U.C)
3. Stats of U.C/ Community Chart
4. Display of IEC material
5. Monthly Performance Report
6. Availability of Drugs & Medicines
7. Display Bin Cards
8. Availability of Contraceptives
9. Availability of Vaccine (EPI)
10. Maintenance of Stock Registers
11. Knowledge of motivation/counseling skills
12. Availability of Medical Equipment Functional Non-Functional

13. Maintenance of Sterilization Functional Non-Functional

B: EMERGENCY MEDICATION/SUPPLIES LIST


Sr. Items
No.
1. Intact oxygen supply
2. ACS protocol
3. IV Adrenaline
4. IV Atropine
5. Functional ECG machine
6. Ambu Bags (Adult mask)
7. Ambu Bags (Pediatric mask)
8. Endotracheal tube (All sizes)
9. Laryngoscope
10. Capoten
11. IV Lasix
12. Labetalol
13. IV Avil
14. Iv Solocortif
15. IV Transamine
16. Omeprazole
17. Salbutamol (Nebulization)
18. Burn Ointment (Silver Sulphadiazine
cream)
19. IV painkillers
20. IV Antibiotics

2
REPLACEMENT INFUSIONS
21. IV N/S
22. R/L
23. D/W (5% and 25%)
24. Haemocoel

OTHERS
25. Cannula (All sizes)
26. IV set with three-way connectors
27. Syringes
28. Sutures
29. Gauzes
30. Pyodine
31. Naso-gastric tube
32. Folleys’s (urinary) catheters+bags

C: INFECTION PREVENTION AND CONTROL PROTOCOLS


Sr. IPC
No.
1. Ventilation Natural Mechanical

2. Seating Arrangement (waiting area)


3. Hand Washing (kiosks/stations)
4. Soaps
5. Sanitizers
6. Masks
7. Gloves
8. Disinfection and Sterilization
9. Waste and Sewage Management
10. Waste Triaging Mechanisms
11. Water Supply Drinking Personal Medical
Water Hygiene Activities

12. Incineration
13. Cleaning materials
14. Injection Safety Devices

3
Remarks:

Special Notes:

(Monitoring Officer)
DHO-ICT

DHO-ICT

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