PHC/CHC(NON FRU) level Monitoring Checklist

Name of District Catchment Population

Name of Block Total Villages

Name of PHC / CHC Date of last supervisory visit

Distance from PHC Date of visit

Name & Designation
of Monitor
Name of staff not available on the day of visit and reason for absence:

SECTION I : PHYSICAL INFRASTRUCTURE

Sl. No. Infrastructure Yes No Remarks
1.1 Health facility easily accessible from nearest road head Y N
1.2 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
1.8 Running 24*7 water supply Y N
1.9 Clean Toilets separate for Male / Female Y N
1.10 Functional and labour room Y N
1.11 Functional and clean toilet accached to labour room Y N
1.12 Functional New Born Care Corner (Functional radiant Y N
warmer with neo-natal ambu bag)
1.13 Functional Newborn Stabilization Unit Y N
1.14 Clean wards Y N
1.15 Separate Male and Female wards (at least by Y N
partitions)
1.16 Availability of complain / suggestion box Y N
1.17 Availability of mechanisms for waste management Y N
SECTION II : HUMAN RESOURCE
Sl. No. Category Numbers Remarks if any
2.1 Mo
2.2 SNs / GNMs
2.3 ANM
2.4 L.Ts
2.5 Pharmacist
2.6 LHV/PHN
2.7 Others
SECTION III : TRAINING STATUS OF HR
Sl. No. Training No. Trained Remarks if any
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

PHCchecklist 1
SECTION IV : EQUIPMENT
Sl. No. Equipment Yes No Remarks
4.1 Functional BP Instrument and Stethoscope Y N
4.2 Sterilised delivery sets Y N
4.3 Functional neonatal, Paediatric and Adult Y N
Resuscitation kit
4.4 Functional Weighing Machine (Adult and Infant / Y N
newborn)
4.5 Functional Needle Cutter Y N
4.6 Functional Radiant Warmer Y N
4.7 Functional Suction Apparatus Y N
4.8 Functional Facility for Oxygen Administration Y N
4.9 Functional Autoclave Y N
4.10 Functional ILR Y N
4.11 Functional Deep Freezer Y N
4.12 Emergency Tray with emergency injections Y N
4.13 MVA / EVA Equipment Y N
Laboratory Equipment
4.14 Functional Microscope Y N
4.15 Functional Hemoglobinometer Y N
4.16 Functional Centrifuge Y N
4.17 Functional Semi Autoanalyzer Y N
4.18 Reagents and Testing Kits Y N
SECTION V : ESSENTIAL DRUGS AND SUPPLIES
Sl. No. Drugs Yes No Remarks
5.1 EDL available and displayed Y N
5.2 Computerised inventory management Y N
5.3 IFA tablets Y N
5.4 IFA tablets (blue) Y N
5.5 IFA syrup with dispenser Y N
5.6 Vit A syrup Y N
5.7 ORS packets Y N
5.8 Zinc tablets Y N
5.9 Inj Magnesium Sulphate Y N
5.10 Inj Oxytocin Y N
5.11 Misoprostol tablets Y N
5.12 Mifepristone tablets Y N
5.13 Antibiotics Y N
5.14 Labelled emergency tray Y N
5.15 Drugs for hypertension, Diabetes, common ailments Y N
e.g PCM, anti-allergic drugs etc.
5.16 Vaccine stock available Y N
5.17 Pregnancy testing kits Y N
5.18 Urine albumin and sugar te Y N
5.19 OCPs Y N
5.20 EC pills Y N
5.21 IUCDs Y N
5.22 Sanitary napkins Y N
5.23 Gloves, Mackintosh, Pads, bandages, and gauze etc. Y N
Note: For all drugs and consumables, availability of at least 2 month stock to be observed and noted
SECTION VI : OTHER SERVICES
Sl. No. Lab tests being conducted for Yes No Remarks
6.1 Haemoglobin Y N
6.2 CBC Y N
6.3 Urine albumin and Sugar Y N
6.4 Serum Bilirubin test Y N
6.5 Blood Sugar Y N
6.6 RPR (Rapid Plasma Reagin) test Y N
6.7 Malaria (PS or RDT) Y N

PHCchecklist 2
 6.8 T.B (Sputum for AFB) Y N
6.9 HIV (RTD) Y N
6.10 Others Y N
SECTION VII : SERVICE DELIVERY IN THE LAST TWO QUARTERS
Sl. No. Availability of at least 2 month stock of essential Drugs Q1 Q2 Remarks
7.1 OPD
7.2 IPD
7.3 Expected Number of pregnancies
7.4 Percentage of women registered in the first trimester
7.5 Percentage of ANC3 out of total registered
7.6 Percentage of ANC4 out of total registered
7.7 Total deliveries conducted
7.8 Number of obstetric complications managed, pls
specify type
7.9 No. of neonates initiated breast feeding within one
hour
7.10 Number of children screened for defects at birth under
RBSK
7.11 RTI/STI Treated
7.12 No. of admissions in NBSUs, if available
7.13 No. of sick children referred
7.14 No. of pregnant women referred
7.15 No. of IUCD insertions
7.16 No. of Tubectomy
7.17 No. of Vasectomy
7.18 No. of Minilap
7.19 No. of children fully immunized
7.20 Measles coverage
7.21 No. of children given ORS + Zinc
7.22 No. of children given Vitamin A
7.23 No. of women who accepted post partum FP services
7.24 No. of MTPs conducted
7.25 Maternal deaths, if any
7.26 Still births, if any
7.27 Neonatal deaths, if any
7.28 Infant deaths, if any
SECTION VII a : SERVICE DELIVERY IN POST NATAL WARDS
Sl. No. Parameters Yes No Remarks
7.1a All mothers initiated breast feeding within one hour of Y N
normal delivery
7.2a Zero dose BCG, Hepatitis B and OPV given Y N
7.3a Counselling on IYCF done Y N
7.4a Counselling on Family Planning done Y N
7.5a Mothers asked to stay for 48 hrs Y N
7.6a JSY payment being given before discharge Y N
7.7a Mode of JSY payment (Cash / bearer cheque / Y N
Account payee cheque / Account Transfer)
7.8a Any expenditure incurred by Mothers on travel, drugs Y N
or diagnostics (Please give details)
7.9a Diet being provided free of charge Y N
SECTION VIII : QUALITY PARAMETER OF THE FACILITY
(Through probing questions and demonstrations assess does the staff nurses and ANMs know how to….)
Sl. No. Essential Skill Set Knowledge Skill Remarks
8.1 Manage high risk pregnancy Y N Y N
8.2 Provide essential newborn care Y N Y N
(thermoregulation, breastfeeding and
asepsis)
8.3 Manage sick neonates and infants Y N Y N
8.4 Correctly uses partograph Y N Y N
8.5 Correctly insert IUCD Y N Y N
8.6 Correctly administer vaccines Y N Y N
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 8.7 Alternate Vaccine Delivery (AVD) Y N Y N
system functional
8.8 Segregate waste in colour coded bins Y N Y N
8.9 Adherence to IMEP protocols Y N Y N
SECTION IX : RECORD MAINTENANCE
Available Available but Remarks /
Not
Sl. No. Record updated and non- Timeline for
available
correctly filled maintained completion
9.1 OPD Register
9.2 IPD Register
9.3 ANC Register
9.4 PNC Register
9.5 Indoor bed head ticket
9.6 Line listing of severely anaemic
pregnant women
9.7 Labour room register
9.8 Partographs
9.9 OT Register
9.10 FP Register
9.11 Immunisation Register
9.12 Updated Microplan
9.13 Drug Stock Register
9.14 Referral Registers (In and Out)
9.15 Payments under JSY
9.16 Untied funds expenditure (Check %
expenditure)
9.17 AMG expenditure (Check %
expenditure)
9.18 RKS expenditure (Check %
expenditure)
SECTION X : REFERRAL LINKAGES IN LAST TWO QUARTERS
Mode of No. of women
No. of sick No. of
Transport transported
Sl. No. JSSK infants children Free /Paid
(Specify during ANC /
transported 1-6 years
Govt / Pvt) INC / PNC

10.1 Home to facility

10.2 Inter facility

10.3 Facility to Home (drop back)

SECTION XI : IEC DISPLAY
Sl. No. Material Yes No Remarks
11.1 Approach roads have directions to the health facility Y N
11.2 Citizen Charter Y N
11.3 Timings of the Health Facility Y N
11.4 List of services available Y N
11.5 Essential Drug List Y N
11.6 Protocol Posters Y N
11.7 JSSK entitlements Y N
11.8 Immunization Schedule Y N
11.9 JSY entitlements Y N
11.10 Other related IEC material Y N
SECTION XII : ADDITIONAL / SUPPORT SERVICES
Sl. No. Material Yes No Remarks
12.1 Regular sterilisation of Labour room (Check Records) Y N
12.2 Functional laundry / washing services Y N
12.3 Availability of dietary services Y N
12.4 Appropriate drug storage facilities Y N
12.5 Equipment maintenance and repair mechanism Y N
12.6 Grievance redressal mechanisms Y N
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 12.7 Tally software implemented Y N
SECTION XIII : PREVIOUS SUPERVISORY VISITS
Place of posting
Sl. No. Name and Designation of the Supervisor Date of visit
of Supervisor
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

Person(s)
Key Findings Action Taken / Proposed Timeline
Responsible

PHCchecklist 5
 Plan of field visits for monitoring

FACILITY MONITORING MINIMUM LEVEL OF OBSERVATION

LEVEL OFFICER
HSC LHV  At least 3 days / week, to one SC per visit
 Every SC will be covered twice a month
 At least 1 VHND / Week
Medical Officer-PHC  At least twice a month to 2 weak performing SCs /
ANMs and 2 VHNDs / Month
CHC Block MO-i/c  At least twice a month to 2 weak performing PHCs and
2 weak performing SCs
Block Programme  At least twice a week ie. 8 times in a month
Manager  2 SCs / Outreach and household assessment
per visit OR
 1 PHC and 1 SC/outreach and household
assessment per visit
District Public Health Nurse  At least twice a week ie. 8 times in a month
 1 PHC and 1 SC per visit OR
 2 SCs, 1 outreach and household assessment
per visit
CMO  At least twice a month to any weak performing facility
and outreach
District Programme  At least once a week ie. 4 times in a month
Manager  1 CHC and 1 SC per visit OR
 2 PHCs and 1 SC per visit OR
 1 PHC, 1 SC, 1 outreach and household
RCHO/ADHO/ACMO  At least once a week ie. 4 times in a month
and other technical  1 CHC and 1 SC per visit OR
officers  2 PHCs and 1 SC per visit OR
 1 PHC, 1 SC, 1 outreach and household
Divisional Regional Programme  At least once a week ie. 4 times in a month to different
Manager / Divisional districts by rotation
Programme Manager  2 CHC-FRUs / SDH per visit OR
 1 CHC-FRU/SDH and 1 PHC per visit OR
 1 PHC, 2 SCs / outreach and household
State Mission Director  At least twice a month to one poor performing district
per visit, Ideally 1 SC, 1 PHC and 1 CHC / DH to be
visited per visit
State Programme  At least twice a month to one poor performing district
Manager per visit. Ideally 1 SC, 1 PHC and 1 CHC/DH to be
visited per visit
Senior Officer of  At least twice a month to one poor performing district
State Directorate / per visit. Ideally 1 SC, 1 PHC and 1 CHC/DH to be
State Technical visited per visit
Programme Officer

 Based on the observations during field visits, plan of action to be made.

 Action Points with timelines and officials responsible for action points to be
uploaded on the State NRHM Website

HSC Checklist 1
 Sub Centre level Monitoring Checklist

Name of District Catchment Population

Name of Block Total Villages

Name of SC Date of last supervisory visit

Distance from PHC Date of visit

Name & Designation of Monitor

Names of staff posted and
available on the day of visit
Name of staff not available on the day of visit and reason for absence:

SECTION I : PHYSICAL INFRASTRUCTURE

Sl. No. Infrastructure Yes No Remarks
1.1 Subcentre located near a main habitation Y N
1.2 Functioning in Govt. building Y N
1.3 Building in good condition Y N
1.4 Electricity with functional power back up Y N
1.5 Running 24*7 water supply Y N
1.6 ANM quarter available Y N
1.7 ANM residing at SC Y N
1.8 Functional labour room Y N
1.9 Functional and clean toilet accached to labour room Y N
1.10 Functional New Born Care Corner (Functional radiant Y N
warmer with neo-natal ambu bag)
1.11 General cleanliness in the facility Y N
1.12 Availability of complain / suggestion box Y N
1.13 Availability of deep burial pit for waste management / Y N
any other mechanism
SECTION II : HUMAN RESOURCE
Specify the
Sl. No. Human Resource Numbers Remarks
Training received
2.1 ANM
2.2 2nd ANM
2.3 MPW – Male
2.4 Others, specify
SECTION III : EQUIPMENT Mark ( √ ) in appropriate column
Available Available
Not
Equipment and but not Remarks
Sl. No. available
functional functional
3.1 Equipment for Hemoglobin Estimation
3.2 Blood sugar testing kits
3.3 BP Instrument and Stethoscope
3.4 Delivery equipment
3.5 Neonatal ambu bag
3.6 Adult weighing machine
3.7 Infant / New born weighing machine
3.8 Needle & Hub Cutter
3.9 Color coded bins
3.10 RBSK pictorial tool kit

HSC Checklist 2
SECTION IV : ESSENTIAL DRUGS
Availability of at least 2 month stock of essential
Sl. No. Yes No Remarks
Drugs
4.1 IFA tablets Y N
4.2 IFA syrup with dispenser Y N
4.3 Vit A syrup Y N
4.4 ORS packets Y N
4.5 Zinc tablets Y N
4.6 Inj Magnesium Sulphate Y N
4.7 Inj Oxytocin Y N
4.8 Misoprostol tablets Y N
4.9 Antibiotics, if any, pls specify Y N
4.10 Availability of drugs for common ailments e.g PCM, Y N
anti-allergic drugs etc.
SECTION V : ESSENTIAL SUPPLIES
Sl. No. Essential Medical Supplies Yes No Remarks
5.1 Pregnancy testing Kits Y N
5.2 Urine albumin and sugar testing kit Y N
5.3 OCPs Y N
5.4 EC pills Y N
5.5 IUCDs Y N
5.6 Sanitary napkins Y N
SECTION VI : SERVICE DELIVERY IN THE LAST TWO QUARTERS
Availability of at least 2 month stock of essential
Sl. No. Q1 Q2 Remarks
Drugs
6.1 Number of estimated pregnancies
6.2 Percentage of women registered in the first trimester
6.3 Percentage of ANC3 out of total registered
6.4 Percentage of ANC4 out of total registered
6.5 No. of pregnant women given IFA
6.6 Number of deliveries conducted at SC
6.7 Number of deliveries conducted at home
6.8 No. of neonates initiated breast feeding within one
hour
6.9 Number of children screened for defects at birth
under RBSK
6.10 No. of sick children referred
6.11 No. of pregnant women referred
6.12 No. of IUCD insertions
6.13 No. of children fully immunized
6.13 a Measles coverage
6.15 No. of children given ORS + Zinc
6.16 No. of children given Vitamin A
6.17 No. of children given IFA Syrup
6.18 No. of Maternal deaths recorded if any
6.19 No. of still birth recorded, if any
6.20 Neonatal deaths recorded, if any
6.21 Number of VHNDs attended
6.22 Number of VHNSC meeting attended
6.23 Service delivery data submitted for MCTS updation
SECTION VII : QUALITY PARAMETERS OF THE FACILITY
Though probing questions and demonstrations assess does the ANM know how to
Sl. No. Essential Skill Set Knowledge Skill Remarks
7.1 Correctly measure BP Y N Y N
7.2 Correctly measure hemoglobin Y N Y N
7.3 Correctly measure urine albumin Y N Y N
and protein
7.4 Identify high risk pregnancy Y N Y N
HSC Checklist 3
 7.5 Awareness on mechanisms for Y N Y N
referral to PHC and FRU
7.6 Correct use of partograph Y N Y N
7.7 Provide essential newborn care Y N Y N
(thermoregulation, breastfeeding
and asepsis)
7.8 Correctly insert IUCD Y N Y N
7.9 Correctly administer vaccine Y N Y N
7.10 Adherence to IMEP protocols Y N Y N
7.11 Segregation of waster in colour Y N Y N
coded bins
7.12 Guidance / Support for breast Y N Y N
feeding method
7.13 Correctly identified signs of Y N Y N
Pneumonia and dehydration
7.14 Awareness on Immunization Y N Y N
Schedule
7.15 Awareness on site of administration Y N Y N
of vaccine
SECTION VIII : RECORD MAINTENANCE Mark ( √ ) in appropriate column
Available and
Available
upto date and Not
Sl. No. Record but non- Remarks
correctly available
maintained
filled
8.1 Untied funds expenditure
(Rs.10,000) Check %
expenditure
8.2 Annual maintenance grant
(Rs.10,000) Check %
expenditure
8.3 Payments under JSY
8.4 VHND plan
8.5 VHSNC meeting minutes and
action taken
8.6 Eligible couple register
8.7 MCH register (as per GOI)
8.8 Delivery Register as per GOI
format
8.9 Stock register
8.10 Due lists
8.11 MCP cards
8.12 Village register
8.13 Referral Registers (in and out)
8.14 List of families with 0-6 years
children under RBSK
8.15 Line listing of severely anemic
pregnant women
8.16 Updated Microplan
8.17 Vaccine supply for each session
day (check availability of all
vaccines)
8.18 Due list and work lan received
from MCTS Portal through
Mobile / Physically
SECTION IX : REFERRAL LINKAGES IN LAST TWO QUARTERS
No. of women No. of sick No. of
Mode of Transport transported during
Sl. No. infants children Free/Paid
(Specify Govt./ pvt) ANC/INC/PNC transported 1-6 years
9.1 Home to facility

9.2 Inter facility

HSC Checklist 4
 9.3 Facility to Home
(drop back)
SECTION X : IEC DISPLAY

Sl. No. Material Yes No Remarks

10.1 Approach roads have directions to the sub Y N
centre
10.2 Citizen Charter Y N

10.3 Timings of the Sub Centre Y N

10.4 Visit schedule of “ ANMs” Y N

10.5 Area distribution of the ANMs / VHND plan Y N

10.6 SBA Protocol Posters Y N

10.7 JSSK entitlements Y N

10.8 Immunization Schedule Y N

10.9 JSY entitlements Y N

10.10 Other related IEC material Y N

SECTION XI : PREVIOUS SUPERVISORY VISITS

Name and Designation of the Place of posting of
Sl. No. Date of visit
supervisor Supervisor

11.1

11.2

11.3

11.4

11.5

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

Actions
Key Findings Person(s) Responsible Timeline
Taken/Proposed

HSC Checklist 5
HOUSEHOLD VISIT (Families with 0 – 6 years children)
Knowledge and 1 2 3 4 5 6 7 8
Indicators Awareness Total
(Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N)
Households
1. Breast Is the mother aware that
Feeding Breast feeding (BF) must
be initiated within one
hour after birth?
Did the mother initiate
BF within one hour of
birth?
Is the mother aware that
Exclusive Breast feeding
should be done for six
months and continued till
chindl attains age of 2
years?
Has the mother
Exclusively Breast fed
her youngest child for six
months and continued
BF till 2 years?
2. Is she aware about
Complementary initiating Complementary
Feeding Feeding (CF) from 6
Practices months onwards?
Has she adhered to
initiating CF from 6
months onwards?
3. Diarrhoea Does the mother know
that ORS+Zinc available
with ASHAs?
As per mother, is
ORS+Zinc available with
ASHAs?
4. Pneumonia Can mother tell at least
two danger signs of
pneumonia?
Is she aware whom to
approach on recognizing
the danger signs?
HOUSEHOLD VISIT (Pregnant Woman / High Risk Pregnant Women)
Key Questions 1 2 3 4 5 6 7 8 Total
Households (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N)
Is the MCP card being regularly filled?*
Is the quality of ANC and regularity of ANCs
adequate?*
Is the pregnant woman aware about birth
preparedness?
Does the pregnant woman have knowledge
of JSY and JSSK?
Whether the pregnant woman has received
safe motherhood booklet?
Does the pregnant woman have the
telephone number of call center for referral
transport / other available referral
transport?
Does the pregnant woman have telephone
numbers of ASHA / ANM?
Is guidance and referral provided along with
birth preparedness in case of high risk
pregnant woman?
* (Probe by questions and verify through filled up MCP card)
HSC Checklist 6
HSC Checklist 7