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Identification/ Infrastructure/Basic Equipment

Instructions:
-------------------------------------
1. Answer "Yes", "No", "N/A" for the questions below.
2. Add photos and notes by clicking on the paperclip icon.
3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date.
4. Complete audit by providing digital signature.
5. Share your report by exporting as PDF, Word, Excel or Web Link.

Infrastructure

Hospital building is seismic proof (Retro-fitting)

Availability of functional electricity supply

Availability of piped water supply

Intact facility boundary wall

All sign boards/sign plates appropriately displayed

Facility building maintained last year

Enough seating available in the waiting area

Female OPD painted & Looks clean

Hospital look clean

Functional toilet for female patients

Labor room functional

Beds with mattresses & clean bed sheets

Functional Nursery

Functional OT sterilization room

Proper heating/cooling in labor room

Separate room/bed for management of Eclampsia

Functional telephone available in emergency department

Basic Equipment

Functional BP apparatus available in emergency department

Functional stethoscope available in OPDs

Functional Thermometer available

Functional weighing machine available in pediatric OPD

Functional small sterilizer available Emergency department

Functional delivery table available in labor room

Height Scale available

Fetoscope

Measuring tape

Autoclave in labor room/OT

Delivery Forceps

Fetal monitor

Anesthesia machine in OT

Incubator

OT lights are all functional

Biochemistry analyzer in laboratory

Suction machines in OT

Functional suction machines in OT

Functional suction machines in labor room

Baby Warmer

Nebulizer

Baby cot

Oxygen Cylinder

Nitrous Oxide

Laryngoscope

Anesthesia Face Mask

Ambu bag for Adult

Ambu bag for Infants

Please proceed to the section.

Human Resource/ Essential Stocks/Material/ Essential Drugs/ Knowledge of Service Providers

Human Resource

Availability of medical officer in the health facility

Availability of lady health visitor (LHV) in the health facility

Availability of dispenser/MHT in the health facility

Availability of at least one support staff in the health facility

Availability of Gynecologist

Availability of Anesthetist

Availability of WMO

Availability of Nurse

Availability of Midwife

Availability of OT Technician

Availability of Blood bank Technician

Availability of Laboratory technician

Availability of Ambulance driver

Availability of Sanitation staff

Essential Stocks/Material

Availability of HIS stationary

Stock out of any essential (tracer) drugs

Availability of anesthetic gases/drugs

Modern FP material available

Essential Drugs

Availability of any type of oral antibiotic syrup for children

Availability of any type of oral antibiotic for adults

Availability of any type of antipyretic drug

Availability of folate/folic acid tablet

Availability of any type of antiseptic solution

Availability of any type of antihypertensive drug

Filled cylinders of nitrous oxide

Availability of any type of injectable antibiotic emergency department

Availability of any type of injectable analgesic in emergency department

Availability of functional and filled oxygen cylinder in OT

Availability of functional and filled oxygen cylinder in labor room

Availability of oral rehydration salt (ORS) sachet

Knowledge of Service Providers

Use pre-agreed criteria for knowledge assessment of relevant staff.

Knowledge on Antenatal Care (ANC) service package delivery

Knowledge on Postnatal Care (PNC) service package delivery

Knowledge of LHV on normal delivery

Knowledge of LHV on assisted delivery

Knowledge of LHV on APH management

Knowledge on management of eclampsia/pre-eclampsia

Knowledge about MISP

Knowledge about management of excessive vaginal bleeding after delivery

Knowledge about puerperal Pyrexia

Knowledge about Management of prolonged labor

Knowledge of LHV on PPH management

Knowledge of Gynecologist/SWMO/WMO on performing C-Section

Knowledge on infection prevention/sterilization

Knowledge on post operative care

Knowledge of dispenser/ or MHT on drugs stock keeping

Please proceed to the next section.

Provision of Health Services/ Infection prevention/waste management

Provision of Health Services

Antenatal Care Services (ANC)

Post Natal Care Services (PNC)

TT Immunization

EPI Services

Hospital based normal vaginal delivery

Provision of contraceptives (FP material)

Cesarean Section

Management of Eclampsia

Medical Indoor services

Gynecology and Obstetrics indoor services

Laboratory services

Radiological services

Ultrasonography

Blood grouping performed

Blood transfusion performed

Parenteral antibiotics administered

Parenteral oxytocic drugs administered

Parenteral anticonvulsant administered

Manual removal of placenta performed

Removal of retained products performed

Assisted vaginal delivery performed

Infection prevention/waste management

Look for availability and functioning of the items.

Functional autoclave

Functional sterilizer

Disposable gloves available

Aprons

Shoe covers/slippers in the LR/OT

Waste bins

Needle/sharp disposal box

Needle cutter

Antiseptic solution

Disposable syringes

Masks

Caps

Macintosh

Intact sewage system

Fly proofing

Inspected by:

Hospital Structured Assessment Checklist

Created by: SafetyCulture Staff | Industry: Health Services | Downloads: 33

Use this template for Hospital Structured Assessment

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Identification/ Infrastructure/Basic Equipment

Instructions:
-------------------------------------
1. Answer "Yes", "No", "N/A" for the questions below.
2. Add photos and notes by clicking on the paperclip icon.
3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date.
4. Complete audit by providing digital signature.
5. Share your report by exporting as PDF, Word, Excel or Web Link.

Infrastructure

Hospital building is seismic proof (Retro-fitting)

Availability of functional electricity supply

Availability of piped water supply

Intact facility boundary wall

All sign boards/sign plates appropriately displayed

Facility building maintained last year

Enough seating available in the waiting area

Female OPD painted & Looks clean

Hospital look clean

Functional toilet for female patients

Labor room functional

Beds with mattresses & clean bed sheets

Functional Nursery

Functional OT sterilization room

Proper heating/cooling in labor room

Separate room/bed for management of Eclampsia

Functional telephone available in emergency department

Basic Equipment

Functional BP apparatus available in emergency department

Functional stethoscope available in OPDs

Functional Thermometer available

Functional weighing machine available in pediatric OPD

Functional small sterilizer available Emergency department

Functional delivery table available in labor room

Height Scale available

Fetoscope

Measuring tape

Autoclave in labor room/OT

Delivery Forceps

Fetal monitor

Anesthesia machine in OT

Incubator

OT lights are all functional

Biochemistry analyzer in laboratory

Suction machines in OT

Functional suction machines in OT

Functional suction machines in labor room

Baby Warmer

Nebulizer

Baby cot

Oxygen Cylinder

Nitrous Oxide

Laryngoscope

Anesthesia Face Mask

Ambu bag for Adult

Ambu bag for Infants

Please proceed to the section.

Human Resource/ Essential Stocks/Material/ Essential Drugs/ Knowledge of Service Providers

Human Resource

Availability of medical officer in the health facility

Availability of lady health visitor (LHV) in the health facility

Availability of dispenser/MHT in the health facility

Availability of at least one support staff in the health facility

Availability of Gynecologist

Availability of Anesthetist

Availability of WMO

Availability of Nurse

Availability of Midwife

Availability of OT Technician

Availability of Blood bank Technician

Availability of Laboratory technician

Availability of Ambulance driver

Availability of Sanitation staff

Essential Stocks/Material

Availability of HIS stationary

Stock out of any essential (tracer) drugs

Availability of anesthetic gases/drugs

Modern FP material available

Essential Drugs

Availability of any type of oral antibiotic syrup for children

Availability of any type of oral antibiotic for adults

Availability of any type of antipyretic drug

Availability of folate/folic acid tablet

Availability of any type of antiseptic solution

Availability of any type of antihypertensive drug

Filled cylinders of nitrous oxide

Availability of any type of injectable antibiotic emergency department

Availability of any type of injectable analgesic in emergency department

Availability of functional and filled oxygen cylinder in OT

Availability of functional and filled oxygen cylinder in labor room

Availability of oral rehydration salt (ORS) sachet

Knowledge of Service Providers

Use pre-agreed criteria for knowledge assessment of relevant staff.

Knowledge on Antenatal Care (ANC) service package delivery

Knowledge on Postnatal Care (PNC) service package delivery

Knowledge of LHV on normal delivery

Knowledge of LHV on assisted delivery

Knowledge of LHV on APH management

Knowledge on management of eclampsia/pre-eclampsia

Knowledge about MISP

Knowledge about management of excessive vaginal bleeding after delivery

Knowledge about puerperal Pyrexia

Knowledge about Management of prolonged labor

Knowledge of LHV on PPH management

Knowledge of Gynecologist/SWMO/WMO on performing C-Section

Knowledge on infection prevention/sterilization

Knowledge on post operative care

Knowledge of dispenser/ or MHT on drugs stock keeping

Please proceed to the next section.

Provision of Health Services/ Infection prevention/waste management

Provision of Health Services

Antenatal Care Services (ANC)

Post Natal Care Services (PNC)

TT Immunization

EPI Services

Hospital based normal vaginal delivery

Provision of contraceptives (FP material)

Cesarean Section

Management of Eclampsia

Medical Indoor services

Gynecology and Obstetrics indoor services

Laboratory services

Radiological services

Ultrasonography

Blood grouping performed

Blood transfusion performed

Parenteral antibiotics administered

Parenteral oxytocic drugs administered

Parenteral anticonvulsant administered

Manual removal of placenta performed

Removal of retained products performed

Assisted vaginal delivery performed

Infection prevention/waste management

Look for availability and functioning of the items.

Functional autoclave

Functional sterilizer

Disposable gloves available

Aprons

Shoe covers/slippers in the LR/OT

Waste bins

Needle/sharp disposal box

Needle cutter

Antiseptic solution

Disposable syringes

Masks

Caps

Macintosh

Intact sewage system

Fly proofing

Inspected by: