Title Page

  • Hospital Name

  • Hospital ID

  • Conducted on

  • Prepared by

  • Location

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.


  • 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:

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