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Supportive Supervision Checklist

F. a,

\

/..J.

. $Hof-RC. C2: Designation. MC tt Ce....,,.._ 3: Level of supervisor - Block/ District / State /National/ Other

CS: Facility !Y~ ·SC/ Non 24 *7 PHC /24*7 PH C/Non- FRU CHC/FRU CHC/SDH/Dk?"AREA HOSP/other

CS: Name of Facility in-charge/nodal officer ·

C6: Faci lity Level · Ll/ L2/ L3

C9: Designation of In-charge­

~

Total Deliveries 66 Normal ';h Assisted Vaginal Delivery

C-section /0 Refer red out cases

Live births

E Dr ugs/supplies availabil ity (If possible, verify physically)

El: Reproductive Health E}: New Born Health p. Antibiotics El.1: !UCO 375, 380A ,....E3. 1: lnj. Vit Kl(l mg/ml) ~ qJ/ E.7 .1 Antibiotics as per RMNCH+A SXS r:J..;..-.----"

Matrix ( Amoxyclillin, Ampicillin, Ampicillin, Gentamicin, Metronidazole, Trimethoprim &Sulpha methoxazole,

V J:efrtiaxone (oral/ lM/IV as applicab le)

El.2: OCP IJJ' E3.2: Mucus Extractor ~ E8: Other essential supplies &equipments(check

~

v functiona lity & utilizat ion) El.3: ECP LEr E3.3: Bag and mask V E8.1 Weighing Machine (!) ..........

02 Number of new-borns

immunized before discharge

03 IPD load

04 OPD load

OS IUCD inserted in facility

[ill

Interva l

Postpartum

Post Abortion

06 Sterilization done

Female interval ste ril ization

Female postpartum sterilizat ion

Male ste rilization

07 No. of clients received

CAC se rvices 08 No of women received IFA tab

09 No. of ANC clients with high risk conditions

2

~ 010 HR deployed/posted in Labor Room

Post Trained in

ed SBA/ PPIUCO NSSK BEmOC

MO !(X . . e) 0 ANM/Sta

6 u Dff nurse D

l240 ml) w ith bot h pre & term mask (size 0,1) g..--­El.4: Condoms ~ E3.4: Clean linen/towels for receiving new born E8.2: Hub cutter with needle destroyer Er

El.5: Mifepristone + Misoprostol (MMA) ~ .--e3.5: Sterile cord cutting equipment 0--- E8.3: Refrigerator D El.6: MVA Kit/EVA \-ef E3.6: Designated Newborn Care Corner 8"' E8.4: RTI/STI Kit D

E3.7: Functional Radiant Warmer E8.5 : Bleaching Powder DE2: Maternal Health ~

E2.1: lnj. Oxytocin (check whether stored E8.6: Oxygen Cylinder functional E4: Child Health 0------'~ in cold box/refrigerator)

E2.2: Tab Misoprostol EL E4.1 ORS ~ E8.7: BP apparatus with stethoscope ~

E2.3: Ant ihypertensive (alpha E4.2: Zinc (10mg & 20 mg) E8.8: Thermometer D~ ~ ~ methyldopa/Labetalol or Nifedipine) E2.4: lnj . Magnesium Sulfate D E4.3 : Syp Salbutamol/Sa lbutamol Nebulizing E8.9: PPIUCD Forceps~ ox'.

Solution"I' E2.5: lnj. Tetanus Toxoid i"\Q-"' j:4.4: Tablet Albendazole m----- E8.10: Fetoscope/ Doppler g----­E2 .6: Sterile pads u3"" E8.11: Autoclave/Boiler E.5 : Adolescent Health u.-­E2.7: IFA Tablet ~ ES.1: Dicyclomine ~ E8.12: Running wa ter ~ E2.8 : Pregnancy Test Kit (only at sub- ,....E5.2: Weekly Iron fo lic acid supplementat ion E8.13: Soap .Q_­~ centres and w ith ASHAs) tablets ~

/

E2.9: Funct ional Blood Bank/blood D E 5.3 Tablet Albendazole p--' E8.14: Color coded bins and bags g___--· storage units X E2. 10 : Haemoglobinometer --a- E8.15: Electricity back-up i::, ­E-9: Vaccines

L,

E2.ll: Urine albumin kit l8"' E6.1: BCG Er E8.16: Toilet near LR t9.­E 2.12: Blood grouping typing r--e- E6.2: '0PV Q/ E 2.13:HIV screening i"tJ _E6.3: Hep B -Q--:-v E 2.14:Hepatitis B screening tff EG.4: OPT ff µ8.17: Cold box, ILR, Deep freezer D--" E2.15: Partograph LP---­ E.6.5: Measles µ---­ present for vaccine storage as per

E2.16: Protocols displayed in LR ir.v­E.6.6: Syrup Vit. A ~ ;equirement

E2. 17: IV Fluids LB- E.6.7: Pentavalent vaccine (in re levant states) e-' E 8.18 MCP cards

E 2.18 lni Dexamethasone __Q..-- - E.6.8 JE Vaccine (where relevant\ GI ~ 0------

Fl. Ante Natal Care

Fl.1 Blood Pressure Measured during ANC visits

Response

S---Ves 0 No D NA

Fl.2 Haemoglobin measured during ANC visits a-res 0 No D NA "

f ' Fl.3 Blood Glucose measured during ANC visits Q.--ves 0 No D NA ; . ·-~ - l Fl.4 Urine Albumin measured during ANC visits g.....--reso No D NA

,, ' Fl.5 Appropriate management/referral of high risk clients (identified on the basis of High BP/ Blood sugar/Haemoglobin) Q-Tes 0 No D NA

Fl.6 Family Planning Counselling happening during ANC visits lu,..--M"' 0 No D NA

F2. Intra- F2.l Fetal Heart Rate (FHR) recorded at the time of admission D--Y""es D No

partum and F2.2 Mother's temperature and BP recorded at the t ime of admission o---Yes D No Immediate F2.3 Partograph used to monitor progress of labor Q--Yes D No post-partum practices

F2.4

F2.5

Antenatal corticosteroids used for preterm labour

Magnesium Sulphate used to manage severe Pre-eclampsia and Eclampsia cases

--o-¥es 0

9( Yes

No

D

D

No

NA

F2.6 Uterotonic (Oxytocin or Misoprostol) given to mother immediately after birth of baby D---Yes D No

F3. Essential F3.l Newborn care corner adequately equipped (bag-and-mask, radiant warmer, mucous extractor, shoulder roll, thermometer, clock, Oxygen source) Q---'fes D No

new born F3.2 Early initiation of breastfeeding practices g-----'Yes D No

care (ENBC) F3.3 Practice of skin to skin contact being promoted g.--yes 0 No and New­born

F3.4 Babies dried with clean and sterile sheets/towels just after delivery UJ-ves 0 No

Resuscitation F3.S Provider aware about the steps of new-born resuscitation (Positioning, suctioning, stimulation, repositioning, PPV using Ambu bag) o--Ves 0 No

(NBR) F3.6 New-borns given BCG,OPV, Hep-B w ithin 24 hours of birth 0-------Ves 0 No

F4. Family F4.1 Family planning counselling being done 0--Y-es 0 N o

Planning F4.2 Postpartum IUCD in sertions being done Yes D No

F4.3 Interval IUCD insertions being done o----fes D No D NA

F4.4

F4.S

Sterilization procedures being done {Fixed Day Services or Fixed day Camps)

Postpartum sterilization being done

1--hryllL--J, I 1.Jd--Yes

C}-----y'es

D D

No

No

FS. Client F.5.l Privacy during delivery? a-------res 0 No

Satisfaction F.5.2 Is transport being provided for drop back? iJ..,---Yes 0 No

F.5.3 Staff was well behaved w ith you during your stay? g...--yes 0 No I•

F.5.4 Were you informed about the procedures before t hey were undertaken lQ- Yes 0 No

F.5.5 Free d iet provided? ia-- Yes 0 No

F.5.6 Would you suggest visiting this facility to your relatives/friends? g/yes D No

FG. FacilityI F6.l Is utilization of untied fund adequate? D Yes D No mechanisms

F6.2 Awareness generation (use of IEC/BCC)- Posters, audio visual aids, display of citizen charter? ~ s D Noand others F6.3 Is grievance redressal mechanism in place? ~.,vr,AVJ,tl-,'vi,--. / /\ , , -·"'~ 6--::>'-- s--res D No

F7 F 7.1 xclusive breastfeeding practised upto six months (no water) , V

/ g_..ves D No Functionality F.7.2 Complementary feeding practised ll--¥es D No of programs

F.7 .3 ORS and Zinc available with ASHAs and distributed in community e-Tes D No at community I

{F.7.4 Growth monitoring at AWW centers and VHNDs 0---Yes D No

F.7.S Malnourished children referred to Nutritional Rehabilitation Centres IZl Yes [9-----No

F.7.6 Incentives to ASHAs for delaying and spacing of births D Yes D No

F.7. 7 Incentives to ASHAs for accompanying clients for PPIUCD insertions D Yes ~

F.7.8 Weekly IFA supplementation {WIFS) D Yes ·llJ.--No F.7.9 Community based distri bution of Misoprostol for PPH prevention D Yes D No ~

F7.10 Home-based new born care by ASHA fJ/Yes D No

F.7.11 HBNC kits available w ith ASHA IIl--feso No

F7. 12 Referra ls of sick newborns or newborns with danger signs being undertaken D Yes D No

F.7.13 Home delivery of contraceptives by ASHAs ~D No 0 NA

F.7.14 Menstrual hygiene practices being promoted LJ;y-y'es 0 No 0 NA F.7. 15 VHNDs being conducted on a monthly basis (Services include ANC, Growth Monitoring, Immu nization, Health Messages etc) D Yes D No

• ' F7.16 JSSK (JSSK entitlements being given?) ~J] No

F7. 17 JSY (JSY entitlem ents being given?) Yes D No

F7.18 Rashtriya Bal Swasthya Karyakram operational D Yes D No

Major findings from last visit

Action taken on interventions/

activities identified from last visit

Plan of Action

Major findings from this visit Intervention/ Activities identified Level of intervention Responsibility Timeline

Reproductive

Health/Family Planning

M aterna l Health

Newbo rn Health I.

Child Health ~ ~~ N./4 c. ~ .s~ ti::r' NJ__ ~i-;J tv~ o/-o Adolescent Health

~