Govt Nurse Office Order - Excel

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Govt Nurse Office Order - Excel Powered By Docstoc
					Name of the District____________                                        Village Data                                                        Annexure - I




                           Name of                     Population          %age of                               School         No. of Connectivi Distance
      Name of    Name of             Name of                                           BPL      Atta Daal
SN                           Sub                                             SC                                               Anganwari ty with   from Sub
     the Block    PHC                 Village   Male   Female   Total                Population Families Primary    Secondary
                            Centre                                        Population                                           Centres   road       Centre




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Name of the District____________                                      Village Data                                                       Annexure - I




                                             Name of                                    No. of       Source of Water Supply   Garbage
                       Name of     Name of             Name of     Distance Distance
                 SN                            Sub                                     Ponds in           Hand                Disposal
                      the Block     PHC                 Village   from PHC from CHC             Tap Water             Other
                                              Centre                                    Village           Pump                System




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Name of District____________                              Infrastructure in Sub Centres                                                  Annexure - II



                                                                  Status OF Building                          If not in             Location
                                                                                                            Govt.Building
                                           Name of Sub                                          Condition                      Within
SN    Name of Block      Name of PHC                                                                             then                      Outside
                                             Centre       Own building   Panchayat     Rented   Building    availability of
                                                                                                                               village
                                                                                                                                           village
                                                                                                                 land         locality




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Name of District____________                              Infrastructure in Sub Centres                                     Annexure - II




                                                                  Name of Sub   Water                    Staff
                         SN    Name of Block     Name of PHC                              Electricity             Toilets
                                                                    Centre      Supply                  Quarter




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Name of the district ____________                     Manpower in Sub Centres                                  Annexure - II
                                                    Name of Sub              ANMs                      MPHW (M)
  SN     Name of Block         Name of PHC
                                                      Centre      Required   Available   Gap   Required Available   Gap




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Name of District___________                            Furniture in Sub Centres                                            Annexure - II


                                               Name of Sub        Examination   Writing   Armless   Medicine   Labour   Wooden
SN      Name of Block       Name of PHC                                                                                        Foot step
                                                 Centre              Table      Table      chairs    chest      table   screen




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Name of District___________                            Furniture in Sub Centres                                       Annexure - II

                                                                                                                   Side
                                                  Name of Sub               Bed side
  SN      Name of Block        Name of PHC                        Coat rack            Stool   Almirahs   Lamp   wooden    Fans
                                                    Centre                   table
                                                                                                                  racks




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Name of District___________                            Furniture in Sub Centres                                     Annexure - II


                                                Name of Sub       Tube     Basin                    Kerosene Sauce pan     Water
 SN      Name of Block       Name of PHC                                           Buckets   Mugs
                                                  Centre          lights   stand                     stove    with lid   receptacle




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Name of District___________                            Furniture in Sub Centres                                           Annexure - II

                                                                                                    Drum with
                                                                                Rubber /
                                                                  Name of Sub            Talquist    tap for   Others
                  SN      Name of Block       Name of PHC                        plastic
                                                                    Centre               Hb scale    storing  (specify)
                                                                                shutting
                                                                                                      water




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Name of the District ____________           Drugs, Medicine Equipment in Sub Centres                               Annexure - II
                                                                                                             Contracep
                                                                                  Drugs
                                                                                            Other     Med.      tives   Drug
                                         Name of Sub                             required
 SN   Name of Block     Name of PHC                       Kit- A Kit- B   Kit-C            Drugs & Required Required List for
                                           Centre                               by ANMs
                                                                                          Vaccines. for NDCP for Family AWC
                                                                                and LHVs
                                                                                                             .Planning




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Name of the District _______________                                    Infrastructre in PHC                                                               Annexure - III




                                                              Condition of
                                                  Building                   Tap                                                Avail .of                        Average
                                       Whether                 Building                       Operation   Labour                                        No. of
 SN   Name of Block     Name of PHC               (Govt. +                  water Electricity                      Laboratory   Quarter     Telephone             No. of
                                        24x7                    (Good +                        Theatre    Room                                          Beds
                                                 Panchayat)                supply                                               for staff                         OPD
                                                                  Fair)




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Name of the District __________                                                           Manpower in PHCs                                                                               Annexure - III




                                                                                                                           Block
                                                                                                      Female Health
                                                     MO             Pharmacist          Nurse                            Extension      Clerks      Lab. Technician      Driver            Class lV
                                                                                                         Worker
                                    Whether                                                                              Educator
SN   Name of Block   Name of PHC
                                     24x7   Required
                                              Available   Gap     Available   Gap   Available   Gap   Available   Gap Available Gap Available Gap   Available   Gap Available     Gap   Available   Gap




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Name of the District ____________                            Equipment in PHCs                                                     Annexure - III


                                                                                                  Standard
                                                                                               Surgical Set (for                  Equipment for
                                                               Equipment for   Equipment for                      Equipment for
                                    Whether   Normal Delivery                                       minor                         New Born Care
  SN Name of Block Name of PHC                                assisted vacuum assisted forceps                   Manual Vacuum
                                     24x7          Kit                                         procedures like                     and Neonatal
                                                                  delivery        delivery                         Aspiration
                                                                                                episiotomies                      Resuscitation
                                                                                                  stitching)




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Name of the District ____________                                 Equipment in PHCs                                                    Annexure - III


                                                                    Equipment /
                                                                                                                    Computer with
                                                                    reagents for
                                    Whether                                                      ILR/Deep   Ice      accessories       Baby warmer/
  SN Name of Block Name of PHC                IUD insertion kit       essential     Refrigerator
                                     24x7                                                         Freezer   box   including internet    incubator
                                                                     laboratory
                                                                                                                        facility
                                                                   investigations




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Name of the District ____________                          Equipment in PHCs                                                     Annexure - III


                                                                                                                     Table                Self
                                                                             Equipments                            lamp with            inflating
                                                       Equipments for Eye                   Radiant warmer
                                Whether    Binocular                        under various                    Baby 200 watt Photother    bag and
SN Name of Block Name of PHC                             care and vision                     for new borne
                                 24x7     microscope                          National                       scale  bulb for apy unit    mask-
                                                             testing                              baby
                                                                            Programmes                             new borne            neonatal
                                                                                                                     baby                 size




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Name of the District ____________                         Equipment in PHCs                                                       Annexure - III
                                                     Mucus
                                        Laryngosc extractor
                                                                                                           MVA syringe and      Kidney
                                         ope and      with
                                                                                                           cannulae of sizes    tray for
                                        Endotrach suction      Feeding    Sponge    Valsellum   Tenaculu                                   Trainer
                                Whether                                                                   4-8 (2 sets; one for emptying
SN Name of Block Name of PHC                 eal   tube and a tubes for   holding    uterine    m uterine                                     for
                                 24x7                                                                     back up in case of contents
                                        intubation    foot      baby      forceps    forceps     forceps                                   tissues
                                                                                                               technical        of MVA
                                           tubes    operated
                                                                                                               problems)        syringe
                                        (neonatal) suction
                                                    machine




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Name of the District ____________                          Equipment in PHCs                                                     Annexure - III

                                                                                  Bowl for
                                                                                                 Tray      Residual
                                                                                 antiseptic
                                                                     Battery dry              containing chlorine in
                                                             Torch                solution                           H2S Strip
                                                 Whether              cells 1.5                chlorine    drinking
                 SN Name of Block Name of PHC               without                  for                               test
                                                  24x7               volt (large             solution for   water
                                                           batteries              soaking                             bottles
                                                                        size)               keeping soiled testing
                                                                                   cotton
                                                                                             instruments     kits
                                                                                   swabs




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Name of the District ____________                                 Furniture in PHCs                                                           Annexure - III



                                                                       Plastic
                                                           Writing chairs (for
                                                                                          Full size                    Arm board
                                     Whether   Examinati tables with     in-    Armless               Labour    OT                Wheel   Stretcher Instrument
SN    Name of Block   Name of PHC                                                          steel                        for adult
                                      24x7      on table    table     patients’  chairs                table   table              chair   on trolley  trolley
                                                                                          almirah                      and child
                                                           sheets    attendants
                                                                          )




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Name of the District ____________                                  Furniture in PHCs                                                           Annexure - III



                                                                                                 Shadowles
                                                                                                    s lamp                                              Sundry
                                                     Bed stead                                                   Side
                     Wooden   Foot   Coat   Bed side               Baby           Medicin         light (for                   Tube            Basin    Articles
SN   Name of Block                                   iron (for in-        Stool             Lamp               Wooden   Fans           Basin
                     screen   step   rack    table                  cot           e chest          OT and                      light           stand   including
                                                      patients)                                                 racks
                                                                                                   Labour                                                Linen:
                                                                                                    room)




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Name of the District ____________                                 Furniture in PHCs                                                           Annexure - III




                                                                                        Drum with                      Foam       Foam     Macintosh  Kelly’s
                                                                           Rubber/pla
                                    LPG       LPG   Sauce pan   Water                    tap for    IV    Mattress   Mattress    Mattress for labour pad for
SN   Name of Block   Buckets Mugs                                             stic
                                    stove   cylinder with lid receptacle                 storing  stand   for beds    for OT    for labour  and OT labour and
                                                                            shutting
                                                                                          water                        table       table     table   OT table




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Name of the District ____________                                 Furniture in PHCs                                    Annexure - III




                                                                    Pillows
                                                            Bed                          Baby              Curtains
                                      SN   Name of Block             with   Blankets              Towels
                                                           sheets                      blankets            with rods
                                                                    covers




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Name of the District _________________                        Drugs Medicines in PHCs                                                            Annexure - III




                                               Essen. &                Anticonvul
                                                                                     Anti-                            Dermatolo Antilep.&             Antiprotoz
                                    Whether     emerg.                   sive./              Antifilarial Antibacteri                      Antifungal
 SN   Name of Block   Name of PHC                          Antidotes               infective                            gical   Antituberc               oal
                                     24x7     obstetrics               Antiepilept                s           al                           medicine
                                                                                   Medicines                          medicine    ullar               medicine
                                              care drugs                   ic




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Name of the District _________________                            Drugs Medicines in PHCs                                                         Annexure - III



                                                                  Hormones,                        Solns.
                                                                            Ophthalmi                                             Product
                                                                  Endocrine                      correcting                                                Drugs &
                     Antiseptic Disinfecta             Gastrointe               c.     Psychotic             Vitamins &  Drugs    Strength    RTI / STI
SN   Name of Block                           Diuretics                &                             water                                                 Consumab
                         s         nts                   stinal             preparatio Disorders              Minerals under RCH formulatio    Drugs
                                                                  Contracep                      Electrolyte                                              le for MVA
                                                                                n                                                  n Units
                                                                    tives                          & Acid-




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Name of the District _________________                          Infrastructure in CHCs                                                            Annexure - IV



                                                                         Water Supply (Tap,
                                             Building    Conditions of
                         Building (Govt. +                                Bore Well/ Hand    Alternate               Labour    Available of         No. of beds
   SN     Name of CHC                        (Rented/   Building (Good +                                    Toilet
                           Panchayat)                                    Pump/ Tube Well, electric supply            Room     Quarter for staff      available
                                              Others)         Fair)
                                                                               Well)




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Name of the District _________________                          Infrastructure in CHCs                                                Annexure - IV




                                         Operation   Waste Disposal                      Generator/               Emergency    Separate wards for
     SN     Name of CHC     Laboratory                              Telephone Computer                Vehicle
                                          Theatre    (Burnt + Dump)                       Invertor              Room/ Casualty males and females




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Name of the District _________________                            Infrastructure in CHCs                                                             Annexure - IV



                                                                                                            Cardiac      Blood       Annual
                                    No. of beds:   No. of beds:   Availability of   X-Ray      Ultrasound                                       Annual
              SN     Name of CHC                                                                            Monitor   Storage Unit    OPD
                                        Male         Female       ECG facilities    facility     facility                                     IPD Cases
                                                                                                            for OT      available    Cases




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Name of the District _________                                         Manpower in CHCs                                                                   Annexure - IV




                                                                                                                 Public Health
                         General                           Obstetrician /                                                                           Other specialists
                                           Physician                          Pediatrics        Anesthetist       Programme        Eye Surgeon
                         Surgeon                           Gynecologist                                                                                 (if any)
                                                                                                                   Manager
           Name of
      SN
            CHC
                     Required

                      Available   Gap   Available   Gap   Available   Gap   Available   Gap   Available   Gap   Available   Gap   Available   Gap   Available   Gap




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Name of the District _________                                            Manpower in CHCs                                                                     Annexure - IV




                 General duty
                                    Public Health                        Staff Nurse/                       Pharmacist /                                            Ophthalmic
               officers (Medical                          ANM                               Dresser                           Lab. Technician   Radiographer
                                       Nurse                               Midwife                          compounder                                               Assistant
                    Officer)
     Name of
SN
      CHC


               Available   Gap     Available   Gap   Available   Gap   Available   Gap   Available    Gap   Available   Gap   Available   Gap   Available   Gap   Available   Gap




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Name of the District _________                                          Manpower in CHCs                                                                      Annexure - IV




                      Ward boys /                                                                                                                       Any other staff
                                         Sweepers          Chaowkidar      OPD Attendant     Statistical Astt.   OT Attendant      Registration Clerk
                     nursing orderly                                                                                                                      (specify)
           Name of
     SN
            CHC


                     Available   Gap   Available   Gap   Available   Gap   Available   Gap   Available   Gap     Available   Gap   Available   Gap      Available   Gap




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     Name of the District ______________                                Equipments in CHCs                                                               Annexure - IV
                                                                                                                        Equip. for Materials
                       Standard   Standard       IUD    Standard              Standard    Standard Standard                                             Equip. for
                                                                   Normal                                    Equip. for Neo-natal   Kit for    Equip.              Equip. for
SN      Name of CHC    Surgical   Surgical    Insertion Surgical              Surgical    Surgical Surgical                                              Labour
                                                                   Delivery                                  Anesthesia Resuscitat  Blood      for OT              Radiology
                         Set-1     Set - II       Kit    Set - III             Set - IV    Set - V  Set - VI                                              room
                                                                                                                           ion      trans.




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 Name of the District ______________                             Furniture in CHCs                                                    Annexure - IV


                                                                              Arm board                                              Height
                    Examinati   Delivery              Bed Side    Stool for                 Saline   Wheel   Stretcher    Oxygen
SN   Name of CHC                           Footstep                           for adult &                                           measuring   Iron bed
                    on Table     Table                 Screen     patients                  stand    chair   on trolley   trolley
                                                                                 child                                                stand




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 Name of the District ______________                          Furniture in CHCs                                                Annexure - IV


                     Bed side   Dressing    Mayo     Instrument Instrument            Attendant Instrument           Wooden
SN   Name of CHC                                                             Bucket                          Chair            Almirah   Swab rack
                      locker     trolley   trolley     cabinet    trolley               stool       tray              table




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Name of the District ______________                        Furniture in CHCs                                           Annexure - IV

                                                                    Waiting
                                                                                                           Bed side
                                                                  bench for Medicine
                       SN     Name of CHC     Mattress   Pilow                          Side rail   Rack   attendant
                                                                   patients / cabinet
                                                                                                              chair
                                                                  attendants




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     Drugs &



SN   Name of CHC
                                                                                        Annexure - V
 Proforma for IPHS Facility Survey of Category I (31-50 Bedded) Sub-District / Sub-Divisional Hospital
Identification


                 Name of the State: ____________________________

                 District:_________________________

                 Sub District / Sub Divison___________________________

                 Location Name of Hospital:________________________


                 Date of Data Collection

                                                                Day      Month   Year

                 Name and Signature of the Person Collecting Data




I. Services
    S.No.
     1.1.        Population covered (in numbers)
     1.2.        Specialist services available (Yes/No)
            a.   General Medicine
            b.   General Surgery
            c.   Obstetric & Gynaecology
            d.   Paediatrics
            e.   Anesthesia
            f.   Orthopedics
            g.   ENT
            h.   Radiologist and Ultrasonologist
            i.   Ophthalmology
            j.   Community Health
            k.   Dermatology and Venerology (Skin & VD)
                 RTI / STI
            l. Dental Care
           m. AYUSH
    1.3.       Diagnostic and other Para Clinical Services (Yes / No)
           a. Laboratory
           b. X-Ray
           c. Ultrasound
           d. ECG
           e. Blood Transfusion and Storage
            f. Physiotherapy
    1.4.       Support Services (Yes / No)
               Finance (Financial accounting and auditing;
           a.
               timely submission of SOEs / UCs)
           b. Medico legal / postmortem
           c. Ambulance Services
           d. Dietary Services
           e. Laundry Services
            f. Security Services
           g. Housekeeping and Sanitation
           h. Inventory Management
            i. Waste Management
               Office     Management       (provision   for
            j.
               computerized medical records)
               Counseling Services for Domestic Violence,
           k.
               Gender Violence, Adolescents, etc.
    1.5.        Service Mix of Procedures in Medical and Surgical Specialities (Yes / No)
Medical
       1.5.1. Pleural Aspiration
       1.5.2. Lumbar Puncture
       1.5.3. Skin scraping for fungus / AFB
       1.5.4. Skin Biopsies
       1.5.5. Abdominal tapping
              OPD Procedures (Including IPD)
       1.5.6. Dressing (Small, Medium and Large)
       1.5.7. Injection (I/M & I/V)
       1.5.8. Catheterisation
 1.5.9.    Steam Inhalation
1.5.10.    Cut down (Adult)
1.5.11.    Enema
1.5.12.    Stomach Wash
1.5.13.    Douche
1.5.14.    Sitz bath
1.5.15.    Blood Transfusion
1.5.16.    Hydrotherapy
1.5.17.    Bowel Wash
           Skin Procedures
1.5.18.    Chemical Cautery
1.5.19.    Electro Cautery
1.5.20.    Intra Lesional Injection
1.5.21.    Biopsy
           Paediatric Procedures
1.5.22.    Immunization (BCG, OPV, DPT, Measles,
           DT) / CH/ORT corner
1.5.23.    Services related to new borne care
      i.   Only cradle
     ii.   Incubator Nebulization equipment
    iii.   Radiant Heat Warmer
    iv.    Phototherapy
     v.    Gases (oxygen)
    vi.    Cut down
           Cardiology Procedures and Diagnostic Tests
1.5.24.    ECG
1.5.25.    Defibrillator Shock
           Physiotherapy Services
           With Electrical Equipments
1.5.26     Short wave diathermy
1.5.27     Ultra Sonic Therapy
1.5.28     Infra Red Lamp (Therapy)
1.5.29     Electric Vibrator
           Eye Specialist Services (Opthalmology)
           OPD Procedures
1.5.30.   Refraction (by using snellen’s chart)
1.5.31.   Prescription for glasses using Trial frame.
1.5.32.   Syringing and Probing
1.5.33.   Foreign Body Removal (conjunctival)
1.5.34.   Foreign Body Removal (Corneal)
1.5.35.   Epilation
1.5.36.   Suture Removal
1.5.37.   Subconj Injection
1.5.38.   Retrobular Injection (Alcohol etc.)
1.5.39.   Tonometry
1.5.40.   Pterygium Excision
1.5.41.   Syringing & Probing
1.5.42.   I & C of chalazion
1.5.43.   Stye
1.5.44.   Conjuctival Resuturing
1.5.45.   Corneal Scraping
1.5.46.   I & D Lid Abscess
1.5.47.   Uncomplicated Lid Tear
1.5.48.   Indirect Opthalmoscopy
1.5.49.   Retinoscopy
          Obstetric & Gynecology Specialist Services
1.5.50.   Episiotomy
1.5.51.   Forceps delivery
1.5.52.   Craniotomy-Dead Fetus/Hydrocephalus
1.5.53.   Caesarean section
          Female Sterilization ( Mini Laparotomy &
1.5.54.   Laparoscopic)
1.5.55.   D&C
1.5.56.   MTP
1.5.57.   Bartholin Cyst Excision
1.5.58.   Suturing Perineal Tears
1.5.59.   Assisted Breech Delivery
1.5.60.   Cervical Cautery
1.5.61.   Normal Delivery
1.5.62.   EUA
       1.5.63. Retained Placenta & MRP
       1.5.64. Suturing Cervical Tear
       1.5.65. Assisted Twin Delivery
                Dental Services
       1.5.66. Dental Caries/Dental Abcess/Gingivitis
       1.5.67. Minor Surgeries, Impaction, Flap
       1.5.68. Trauma including Vehicular Accidents
       1.5.69. Sub Mucus Fibrosis (SMF)
       1.5.70. Scaling and Polishing
       1.5.71. Root Canal Treatment
       1.5.72. Extractions
       1.5.73. Amalgum Filling (Silver)
       1.5.74. Intra oral X-ray
       1.5.75. Complicated Extractions (including suturing of
               gums)
Surgical
       1.5.76. Abcess drainage including breast & perianal
       1.5.77. Wound Debridement
       1.5.78. Appendicectomy
       1.5.79. Fissurotomy or fistulectomy
       1.5.80. Hemorrohoidectomy
       1.5.81. Circumcision
       1.5.82. Hydrocele surgery
       1.5.83. Herniorraphy
       1.5.84. Suprapubic Cystostomy
       1.5.85. Vasectomy
       1.5.86. Cysts and Benign Tumour of the Palate
       1.5.87. Excision Submucous Cysts
               Breast
       1.5.88. Excision fibroadenoma – Lump
               Hernia
       1.5.89. Ingunial Hernia repair reinforcement
       1.5.90. Femoral Hernia repair
               Strangulated Ventral or Incisional
       1.5.91. Hernia/Ingunial
               Abdomen
       1.5.92. Exploratory Laparotomy
       1.5.93. Gastrostomy or Jejuncstomy
 1.5.94. Simple Closure of Perforated Ulcer
         Pancreas
 1.5.95. Drainage of Pseudopancreatic Cyst
 1.5.96. Retroperitoneal Drainage of Abscess
         Appendix
 1.5.97. Emergency Appendisectomy
 1.5.98. Interval Appendisectomy
 1.5.99. Appendicular Abscess Drainage
         Small Intestine
1.5.100. Resection and Anastomosis
1.5.101. Multiple Resection and Anaestomosis
1.5.102. Intestinal Performation
         Liver
1.5.103. Open Drainage of liver abscess
1.5.104. Drainage of Subdia, Abscess/Perigastric
         Abscess
          Biliary System
1.5.105. Cholecystostomy
1.5.106. Cholecystectomy
1.5.107. Cholecystectomy and Choledocholithotomy
         Colon, Rectum and Anus
1.5.108.   Fistula in anus low level
1.5.109.   Catheters
1.5.110.   IV Sets
1.5.111.   Colostomy Bags
1.5.112.   Fistula in ano high level
1.5.113.   Perianal Abscess
1.5.114.   Ischiorectal Abscess
1.5.115.   Ileostomy or colostomy alone
1.5.116.   Haemorroidectomy
1.5.117.   Anal Sphincter Repair after injury
           Penis, Testes, Scrotum
1.5.118.   Circumcision
1.5.119.   Partial amputation of Penis
1.5.120.   Total amputation of Penis
1.5.121.   Orchidopexy (Unilateral & Bilateral)
1.5.122.   Orchidectomy (Unilateral & Bilateral)
1.5.123.   Hydrocele (Unilateral & Bilateral)
1.5.124. Excision of Multiple sebaceous cyst of scrotal
         skin
1.5.125. Reduction of Paraphimosis
          Other Procedures
1.5.126. Suture of large laceration
1.5.127. Suturing of small wounds
1.5.128. Excision of sebaceous cyst
1.5.129. Small superficial tumour
1.5.130. Repair torn ear lobule
1.5.131. Incision and drainage of abscess
1.5.132. Injection Haemorrhoids/Ganglion/Keloids
1.5.133. Removal of foreign body (superficial)
1.5.134. Removal of foreign body (deep)
1.5.135. Excision Multiple Cysts
1.5.136. Tongue Tie
1.5.137. Debridment of wounds
1.5.138. Excision carbuncle
1.5.139. Ingroving Toe Nail
1.5.140. Diabetic Foot And carbuncle
          Urology
1.5.141. Pyelolithotomy
1.5.142. Nephrolithotomy
1.5.143. Uretrolithotomy
1.5.144. Open Prostectomy
1.5.145. Cystolithotomy Superopubic
1.5.146. Dialatition of stricture urethra under GA
         Dialation of stricture urethra without
1.5.147. anaesthesia
1.5.148. Meatotomy
1.5.149. Trocar Cystostomy
          Plastic Surgery
1.5.150. Burn Dressing Small, medium (10% to 30%),
         large 30% to 60%, extensive > 60%
1.5.151. Ear lobules repair one side
1.5.152. Simple wound
1.5.153. Complicated wound
1.5.154. Simple injury fingers
1.5.155. Crush injury hand
1.5.156. Polio Surgery
1.5.157. Surgery concerning disability with Leprosy
1.5.158. Surgery concerning with TB
         Orthopaedic Surgery
            Fractures
1.5.159. Open reduction int, fixation of femur, tibia, B.
         Bone, Forearm Humerus inter-condylar
         fracture of humerus and femur and open
         reduction and int. Fixation bimaleolar fracture
         and fracture dislocation of ankle montaggia
         fracture dislocation
1.5.160.
         Medial condyle of humerus fracture lateral
         condyle of humerus Olecranen fracture, head
         of radius lower end of radius, medial malleolus
         patella fracture and fracture of calcaneum talus
         single forearm, bone fracture
1.5.161. Ext. fixation of hand & foot bones
1.5.162. Tarsals, Metatarsals, Phalanges carpals,
         Metacarples, excision head fibula, lower and
         of Inia
1.5.163. Interlocking nailing of long bones
1.5.164. Debridement & Secondary closure
1.5.165.
         Percutaneous Fixation (small and long bones)
            Closed Reduction
1.5.166. Hand, Foot bone and cervicle
1.5.167. Forearm or Arm, Leg, Thigh, Wrist, Aknle
1.5.168. Dislocation elbow, shoulder, Hip, Knee
1.5.169. Closed Fixation of hand / foot bone
            Open Reduction
1.5.170. Shoulder dislocation, knee dislocation
         Acromiocalvicular or stemoclavicular Jt.
1.5.171. Clavicle
1.5.172. Wrist dislocation on intercarpal joints
1.5.173. MP & IP Joints
1.5.174. Debridement of hand/foot
         Fibula Radius Ulna (Clavicle) and Wrist,
1.5.175. Ankle, Hand foot
         Amputation (Thigh or arm, leg or forearm, feet
1.5.176. or hand, digits)
               POP Aplication (Hip Spica, Shoulde spica
      1.5.177. POP Jacket; A-K/A-E POP; B-K/B-E POP)
      1.5.178. Patellectomy

II. Physical Infrastructure
                                                                  Current Availability in the Hospital   Remarks
           2.1. Size (Area) of the Hospital (In Sq. Meters)
           2.2. Number of indoor beds available
Location
          2.3. Is the hospital located near residential area?
               (Yes / No)
          2.4. Is the hospital building free from danger of
               flooding? (Yes / No)
          2.5. Is the hospital located in an area free from
               pollution of any kind including air, noice,
               water and land pollution? (Yes /No)
          2.6. Is    necessary     environmental      clearance
               obtained? (Yes / No)
          2.7.
               Whether hospital building is diabled friendly
               as per provisions of Disability Act? (Yes / No)
Building Status
          2.8. What is the present stage of construction of the
               building (Complete: 1; Incomplete: 0)
          2.9. Compound Wall / Fencing (1-All around; 2-
               Partial; 3-None)
         2.10. Condition of plaster on walls (1- Well
               plastered with plaster intact every where; 2-
               Plaster coming off in some places; 3- Plaster
               coming off in many places or no plaster)
         2.11. Condition of floor (1- Floor in good condition;
               2- Floor coming off in some places; 3- Floor
               coming off in many places or no proper
               flooring)
Building Requirements (Availability to be recorded in Yes / No)
         2.12. Administrative Block
         2.13. Circulation Area
         2.14. Entrance Area
         2.15. Ambulatory Care Area (OPD)
2.16. Waiting Spaces adjacent to each consultation
       and treatment room
2.17. Registration Counter
2.18. Assistance and Enquiry Counter
2.19. Departments / Clinics
   a. General
   b. Medical
   c. Surgical
   d. Ophthalmic
   e. ENT
    f. Dental
   g. Obstetric & Gynaecologist
   h. Paediatrics
    i. Dermatology & Venereology
    j. Psychiatry
   k. Neonatology
    l. Orthopaedic
   m. Social Service
   n.
       Infectious & Communicable Diseases located
       in remote corner with independent access
   o. National Health Programmes
2.20. Nursing Stations
2.21. Diagnostic Services
   a. X-Ray Room
   b. Dark Room for X-Ray film developing and
       processing
   c. X-Ray Reporting Room for Doctor
   d. Is X-Ray room accessible to OPD, Wards and
       Operation Theatre?(Yes / No)
   e. Ultrasound Room
    f. Is Ultrasound room accessible to OPD, Wards
       and Operation Theatre?(Yes / No)
   g. Ultrasound Reporting room for Doctors
2.22. Clinical Laboratory
   a. Fully equipped laboratory
   b. Sample Collection Room with facility for
       quick diagnosis of blood, urine, etc.
   c. Separate reporting room for Doctors
2.23. Blood Bank
   a. Fully equipped Blood Bank
   b. Is the blood bank located in close proximity to
       pathology department and at an accessible
       distance to Operation Theatre, ICU,
       Emergency and Accident department? (Yes /
       No)
   c. Separate reporting room for Doctors
2.24. Intermediate Care Area (Inpatient Nursing Units)
   a. General Wards (Number to be given)
    i. Male
   ii. Female
  iii. Total
   b. Private Wards (Number to be given)
   c. Wards for Specialities (Number to be given)
   d. Nursing Stations (Number to be given)
   e. Doctors' Duty Room
    f. Pantry
   g. Isolation Room
   h. Treatment Room
     i Nursing Store
    j. Toilets
2.25. Pharmacy (Dispensary)
   a. Medical Store facility for indoor patients
       Separate pharmacy with accessibility for OPD
   b. patients
2.26. Intensive Care Unit (ICU) & High Dependency Wards
   a. Number of beds available in ICU
       Number of beds available in High Dependency
   b. Wards
   c. Changing Room
       Is the unit located close to OT, X-Ray and
   d. Pathology department? (Yes / No)
   e. Essential Specialised Services
    i.       Piped Suction
   ii.       Medical Gases
  iii.       Uninterrupted Electric Supply
  iv.          Heating
   v.          Ventilation
  vi.          Central Air Conditioning
   f.     Nurses' Station
   g.     Clean Utility Area
   h.     Equipment Room
2.27.     Critical Care Area (Emergency Services)
   a.     Critical Care Area with independent entry
   b.     Adequate space for free passage of vehicles
   c.     Covered area for alighting patients
2.28.     Operation Theatre
   a.     Fully equipped Operation Theatre
          Location of OT in close relation to ICU,
   b.     Radiology, Pathology, Blood Bank
   c.     Specialized Services in OT
    i.      Piped suction and medical gases
   ii.      Uninterrupted Electric Supply
  iii.      Heating
  iv.       Air Conditioning
   v.       Ventilation
  vi.        Efficient Life Service
   d.     Other Rooms adjoining OT
    i.       Preparation Room
   ii.      Pre-operative Room
  iii.      Post-operative Room
  iv.       Scrub-up Room for washing and scrubbing
   v.       Sub-sterilizing Unit
2.29.     Delivery Suit Unit
   a.     Fully equipped Delivery Suit Unit located near
          OT
    b.    Facilities in Delivery Suit Unit
     i.     Reception and admission
    ii.     Examination and Preparation Room
  iii.      Labour Room (clean and a septic room)
   iv.      Delivery Room
    v.      Neo-natal Room
   vi.      Sterilizing Rooms
  vii.      Sterile Store Room
 viii.      Scrubbing Room
   ix.      Dirty Utility
2.30.     Physiotherapy
   a. Physiotherapy department located at a
      convenient access to both outdoor and indoor
      patients
   b. Facilities
    i. Physical and electro-therapy rooms
   ii. Gymnasium
  iii. Office
  iv. Store
   v. Separate toilets for male and female
2.31. Hospital Services
   a. Hospital Kitchen (Diatary Service)
   b.
      Central Sterile and Supply Department (CSSD)
    i. CSSD located
   ii. Easily accessible to OT
  iii. Provision of hot water supply
   c. Hospital Laundry
   d. Medical and General Stores
   e. Mortuary
2.32. Engineering Services
   a. Electric Engineering
    i. Electirc Sub Station and standby generator
      room
   ii. Emergency Lighting (shadowless light in
      OT and Delivery Rooms and portable light
      units in Wards and Departments
  iii. Call Bells
  iv.
        Ventilation (Natural or mechanical exhaust)
   b. Mechanical Engineering
    i. AC and Room Heating in OT and Neo-natal
   ii. Air coolers or hot air convectors
  iii. Water coolers and Refrigerators
   c. Public Health Engineering
    i. Water Supply
    1        Round the clock pipoed water supply
    2        Overhead water storage tank with
             pumping and boosting arrangements
    3        Separate provision for fire fighting and
             water softening plants
   ii. Drainage and Sanitation
                  Proper drainage and sanitation system for
                  waste water, surface water, sub soil water and
                  sewerage
           iii.      Waste Disposal System
                  Proper waste disposal system as per National
                  Guidelines
           iv.       Trauma Centre
            d.    Fire Protection
            e.    Telephone and Intercom
             f.   Medical Gas
            g.    Cooking Gas
            h.    Laboratory Gas
             i.   Office-cum-store for maintenance work
             j.   Parking place
            k.    Administrative Services
             i.      General Section
            ii.      Medical Records Section
             l.   Committee Room
           m.     Residential Quarters for all medical and para
                  medical staff


III. Manpower
    A.            Doctors
                                                                                  Current
                                                                               Availability at
                                                                                               Remarks / Suggestions
   S.No.                            Personnel                      IPHS Norm     Hospital
                                                                                                 / Identified Gaps
                                                                                 (Indicate
                                                                                Numbers)
    1                                     1                            1
                  Hospital Superintendent
    2             Medical Specialist                                   1
    3             Surgery Specialists                                  1
    4             O&G specialist                                       1
    5             Dermatologist / Venereologist                        1
    6             Paediatrician                                        1
    7             Anesthetist                                          1
    8             Opthalmologist                                       1
    9             Orthopedician                                        1
        10        Radiologist                                                       1
        11        Casualty Doctors / General Duty Doctors                           7
        12        Dental Surgeon                                                    1
        13        Forensic Specialist                                               1
        14        ENT Surgeon                                                       1
        15                            2                                             2
                  AYUSH Physician
                  Total                                                            22
    1
        May be a Public Health Specialist or management specialist trained in public health
    2
        Provided there is no AYUSH hospital / dispensary in the district headquarter
        B.        Para-Medicals
                                                                                                 Current
                                                                                              Availability at
                                                                                                              Remarks / Suggestions
    S.No.                            Personnel                               IPHS Norm          Hospital
                                                                                                                / Identified Gaps
                                                                                                (Indicate
                                                                                               Numbers)
         1        Staff Nurse                                                      18
         2        Hospital worker (OP/ward +OT+ blood bank)                         5
         3        Sanitary Worker                                                   5
         4        Ophthalmic Assistant / Refractionist                              1
         5        ECG Technician                                                    1
                  Laboratory Technician* ( Lab + Blood Storage
         6                                                                       5(3+2)
                  Unit)
         7        Laboratory Attendant (Hospital Worker)                            2
         8        Radiographer                                                      2
         9                   1                                                      4
                  Pharmacist
        10        Matron                                                            1
        11        Physiotherapist                                                   1
        12        Statistical Assistant                                             1
        13        Medical Records Officer / Technician                              1
        14        Electrician                                                       1
        15        Plumber                                                           1
                  Total                                                            49
* Must have MLT qualification.
1
  One from AYUSH.


        C.        Administrative Staff
                                                                                                            Current
                                                                                                         Availability at
                                                                                                                         Remarks / Suggestions
     S.No.                           Personnel                                  IPHS Norm                  Hospital
                                                                                                                           / Identified Gaps
                                                                                                           (Indicate
                                                                                                          Numbers)
       1         Office Superintendent                                                 1
       2         Accountant                                                            2
       3         Computer Operator                                                     6
       4         Driver                                                                1
       5         Peon                                                                  2
       6         Security Staff*                                                       2
                 Total                                                                14
Note: Drivers post will be in the ratio of 1 Driver per 1 vehicle . Driver will not be required if outsourced
* The number would vary as per requirement and to be outsourced.



      D.         Operation Theatre
                                                                                                            Current
                                                                                                         Availability at
                                                                                                                         Remarks / Suggestions
     S.No.                              Staff                                   IPHS Norm                  Hospital
                                                                                                                           / Identified Gaps
                                                                                                           (Indicate
                                                                                                          Numbers)
       1         Staff Nurse                                                           2
       2         OT Assistant                                                          2
       3         Sweeper                                                               1
                 Total                                                                 5



      E.         Blood Storage
                                                                                                            Current
                                                                                                         Availability at
                                                                                                                         Remarks / Suggestions
     S.No.                              Staff                                   IPHS Norm                  Hospital
                                                                                                                           / Identified Gaps
                                                                                                           (Indicate
                                                                                                          Numbers)
       1         Staff Nurse                                                           1
       2         MNA / FNA                                                             1
     3          Blood Bank Technician                                     1
     4          Sweeper                                                   1
                Total                                                     4




IV. Investigative & Laboratory Services

                                                               Current Availability at
                                                                                         Remarks / Suggestions / Identified
   S. No.           Speciality / Diagnostic Services / Tests         Hospital
                                                                                                      Gaps
                                                                    (Yes / No)
    4.1.        CLINICAL PATHOLOGY
     a.         Haematology
              i. Haemoglobin estimation
             ii. Total Leucocyte count
             iii. Differential Leucocyte count
             iv. Absolute Eosinophil count
              v. Reticulocyte count
             vi. Total RBC count
            vii. E.S.R.
            viii. Bleeding time
             ix. Clotting time
              x. Peripheral Blood Smear
             xi. Malaria/Filaria Parasite
            xii. Platelet count
            xiii. Packed Cell volume
            xiv. Blood grouping
            xv. Rh typing
            xvi. Blood Cross matching
     b.          Urine Analysis
         i. Urine for Albumin
        ii. Sugar
        iii. Deposits
        iv. bile salts
         v. bile pigments
        vi. acetone
       vii. specific gravity
       viii. Reaction (pH)
 c.          Stool Analysis
         i. Stool for Ova cyst (Eh)
        ii. Hanging drop for V. Cholera
       iii. Occultblood
4.2.         PATHOLOGY
          i. Sputum cytology
4.3.         MICROBIOLOGY
          i. Smear for AFB, KLB (Diphtheria)
         ii. Grams Stain for Throat swab, sputum etc.
       iii. KOH study for fungus
4.4.         SEROLOGY
          i. RPR Card test for syphillis
         ii. Pregnancy test (Urine gravindex)
       iii. WIDAL test
        iv. Rapid Test for HIV, HBs Ag, HCV
4.5.         BIOCHEMISTRY
          i. Blood Sugar
         ii. Blood urea
       iii. Serum bilirubin
        iv. Liver function tests
         v. Kidney function tests
        vi. Blood Cholesterol
       vii. Blood uric acid
4.6.         CARDIAC INVESTIGATIONS
          i. ECG
4.7.         OPHTHALMOLOGY
          i. Refraction by using Snellen's chart
         ii. Retinoscopy
       iii. Ophthalmoscopy
            iv. Syringing
             v. Tension
    4.8.        RADIOLOGY
             i. Xray for Chest, Skull, Spine, Abdomen, bones
             ii. Dental Xray
            iii. Ultrasonography

V. Capacity Building
                Whether medical and paramedical staff
           5.1. undergoing Continuing Medical Education
                (CME) at intervals? (Yes / No)
                Whether medical and paramedical staff
                working in the institutions below sub-district
           5.2. level provided training such as Skill Birth
                Attendant and other skill development /
                management training? (Yes / No)



VI (A). Equipment & Furniture (As per list in IPHS)

                                                                              Remarks / Suggestions / Identified
 Equipment                               Available               Functional
                                                                                           Gaps




VI (B). Drugs (As per drug list in IPHS)

                                                                              Remarks / Suggestions / Identified
   Drug                                         Available
                                                                                           Gaps
VII. Quality Control
   S.No.                       Particular                      Whether functional / available as per norms   Remarks
    7.1.   Citizen's charter (Yes/No)
           Constitution of Rogi Kalyan Samiti (Yes/No) (give
    7.2.
           a list of office order notifying the members)
           Internal monitoring (Social audit through
           Panchayati Raj Institution / Rogi Kalyan Samitis,
           medical audit, technical audit, economic audit,
    7.3.
           disaster preparedness audit, monitoring of
           accessibility and equity issues, information
           exchange etc. (Specify)
           External monitoring (Monitoring by PRI (Zila
    7.4.   Parishad)/ Rogi Kalyan Samitis, service /
           performance evaluation by independent agencies

    7.5.   Monitoring of Laboratory (Internal & External
           Quality Assessment Scheme
    7.6.   Record Maintenance (Use of computers with
           connectivity to District Health System, State and
           National Level
                                     Infrastructure Sub Divisional Hospital                       Annexure - V
Name of the District ______________

        SN                     Facility                                       SDH1                SDH2
                                                          Required   Availability  Gap   Availability    Gap
         1 Bed Capacity

         2 Services

         3 Population covered (in numbers)

         4 Specialist services available (Yes/No)

         5 General Surgery

         6 Obstetric & Gynecology

         7 Pediatrics

         8 Anesthesia

         9 Orthopedics

        10 ENT

        11 Radiologist and Ultra-sonologist

        12 Ophthalmology

        13 Dental Care

        14 Diagnostic and other Para Clinical Services
           (Yes / No)
        15 Laboratory

        16 X-Ray

        17 Ultrasound

        18 ECG

        19 Blood Transfusion and Storage

        20 Physical Infrastructure

        21 Number of indoor beds available

        22 Building Status

        23 What is the present stage of construction of
           the building
        24 Compound Wall / Fencing

        25 General condition




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                                     Infrastructure Sub Divisional Hospital    Annexure - V
Name of the District ______________

        SN                       Facility                              SDH1   SDH2
        26 Building Requirements (Availability to be
           recorded in Yes / No)
        27 Administrative Block

        28 Departments / Clinics

        29 General

        30 Medical

        31 Surgical

        32 Ophthalmic

        33 ENOT

        34 Dental

        35 Obstetric & Gynecologist

        36 Pediatrics

        37 Dermatology & Venereology

        38 Psychiatry

        39 Neonatology

        40 Orthopedic

        41 Diagnostic Services

        42 Fully equipped Blood Bank

        43 General Wards

        44 Male

        45 Female

        46 Nursing Stations

        47 Doctors' Duty Room

        48 Toilets




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                                    Manpower in Sub Divisional Hospital                     Annexure - V
Name of the District ______________

          SN                Name of Staff                                SDH1              SDH2
                                                       Required  Available    Gap   Available   Gap
                                                      MEDICAL STAFF
           1 Hospital Superintendent

           2 Medical Specialist

           3 Surgery Specialists

           4 O&G specialist

           5 Dermatologist / Venereologist

           6 Pediatrician

           7 Anesthetist

           8 Ophthalmologist

           9 Orthopedician

          10 Radiologist

          11 Casualty Doctors / General Duty
             Doctors
          12 Dental Surgeon

          13 Public Health Manager1

          14 Forensic Specialist

          15 ENT Surgeon

          16 AYUSH Physician2

                                                  PARA MEDICAl STAFF


          17 Staff Nurse

          18 Hospital worker(OP/Ward+OT+Blood
             Bank
          19 Sanitary worker

          20 Opthomalic Assistant/Refractionist

          21 ECG Technician

          22 Laboratory Technician ( Lab + Blood
             storage)
          23 Laboratory Attendant (Hospital Worker)

          24 Radiographer



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                                     Manpower in Sub Divisional Hospital                      Annexure - V
Name of the District ______________

          SN                Name of Staff                                  SDH1              SDH2
                                                        Required   Available    Gap   Available   Gap
          25 Pharmacist

          26 Matron (including assistant matron)

          27 Physiotherapist

          28 Statistical Assistant

          29 Medical Records Officer / Technician

          30 Electrician

          31 Plumber

                                                    ADMINISTRATIVE STAFF


          32 Office Superintendent

          33 Accountant

          34 Computer Operator

          35 Driver

          36 Peon

          37 Security Staff*

                                               OPERATION THEATRE STAFF


          38 Staff Nurse

          39 OT Assistant

          40 Sweeper

          41 Total

                                                   BLOOD STORAGE STAFF


          42 Staff Nurse

          43 MNA / FNA

          44 Blood Bank / Storage Technician

          45 Sweeper




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                                                                                       Annexure - VI
              Proforma for IPHS Facility Survey of Category I (101-200 Bedded) District Hospital

Identification


                    Name of the State: ____________________________

                    District:_________________________


                    Location Name of Hospital:________________________


                    Date of Data Collection

                                                                       Day   Month   Year

                    Name and Signature of the Person Collecting Data



I. Services
    S.No.
     1.1.           Population covered (in numbers)
     1.2.           Specialist services available (Yes/No)
               a.   General Medicine
               b.   General Surgery
               c.   Obstetric & Gynaecology
               d.   Paediatrics including Neonatology
                    Emergency (Accident & other emergency)
               e.
                    (Casualty)
               f.   Critical Care (ICU)
              g.    Anaesthesia
              h.    Ophthalmology
               i.   ENT
               j.   Dermatology and Venerology (Skin & VD) RTI / STI
              k.    Orthopedics
               l.   Radiology
              m.    Dental Care
              n.    Public Health Management
     1.3.           Para Clinical Services (Yes / No)
               a.   Laboratory
               b.   X-Ray
               c.   Ultrasound
               d.   ECG
               e.   Blood Transfusion and Storage
               f.   Physiotherapy
               g.   Dental Technology (Dental Hygiene)
               h.   Drugs and Pharmacy
   1.4. (a)         Support Services (Yes / No)


                                                                                                       60
                i.   Medico-legal/postmortem
                ii   Ambulance services
               iii   Dietary services
               iv    Laundry services
                v    Security services
               vi    Counseling services for domestic violence,
                     gender violence, adolescents, etc. Gender and
                     socially sensitive service delivery be assured.
               vii   Waste management
              viii   Ware housing/central store
                ix   Maintenance and repair
                 x   Electric Supply (power generation and
                     stabilization)
             xi      Water supply (plumbing)
            xii      Heating, ventilation and air-conditioning
           xiii      Transport
           xiv       Communication
            xv       Medical Social Work
           xvi       Nursing Services
          xvii       Sterilization and Disinfection
         xviii       Horticulture (Landscaping)
           xix       Lift and vertical transport
            xx       Refrigeration
   1.4.(b)           Administrative Services
                     Finance (Financial accounting and auditing;
                 i
                     timely submission of SOEs / UCs)
                     Medical records (Provision should be made for
                     computerized medical records with anti-virus
                ii
                     facilities whereas alternate records should also
                     be maintained)
              iii    Procurement
               iv    Personnel
                v    Housekeeping and Sanitation
               vi    Education and Training
              vii    Inventory Management
                     Services under various National Health and
  1.4. (c )
                     Family Welfare Programmes
   1.4. (d)          Epidemic Control and Disaster Preparedness



    1.5.             Service Mix of Procedures in Medical and Surgical Specialities (Yes / No)
Medical
           1.5.1     Pleural Aspiration
           1.5.2     Pleural Biopsy
           1.5.3     Bronchoscopy
           1.5.4     Lumbar Puncture
           1.5.5     Pericardial tapping
           1.5.6     Skin scraping for fungus / AFB
           1.5.7     Skin Biopsies



                                                                                                 61
 1.5.8     Abdominal tapping
 1.5.9     Liver Biopsy
1.5.10     Liver Aspiration
1.5.11     Fibroptic Endoscopy
1.5.12     Peritoneal dialysis
1.5.13     Hemodialysis
1.5.14     Bone Marrow Biopsy
           OPD Procedures (Including IPD)
1.5.15     Dressing (Small, Medium and Large)
1.5.16     Injection (I/M & I/V)
1.5.17     Catheterisation
1.5.18     Steam Inhalation
1.5.19     Cut down (Adult)
1.5.20     Enema
1.5.21     Stomach Wash
1.5.22     Douche
1.5.23     Sitz bath
1.5.24     CVP Line
1.5.25     Blood Transfusion
1.5.26     Hydrotherapy
1.5.27     Bowel Wash
            Skin Procedures
1.5.28     Chemical Cautery
1.5.29     Electro Cautery
1.5.30     Intra Lesional Injection
1.5.31     Biopsy
            Paediatric Procedures
1.5.32     Immunization (BCG, OPV, DPT, Measles, DT)
           / CH/ORT corner
1.5.33     Services related to new borne care
      i.   only cradle
     ii.   Incubator
    iii.   Radiant Heat Warmer
    iv.    Phototherapy
     v.    Gases (oxygen)
    vi.    Pulse Oxementer
   vii.    Lum bar Puncture
   viii    Bone Marrow
     ix    Exchange Transfusion
      x    Cut down
     xi    Plural/Acite Tap
    xii    Ventilator
   xiii    Live Biopsy u/s guided
            Cardiology Procedures and Diagnostic Tests
1.5.34     ECG
1.5.35     TMT
1.5.36     Holter


                                                         62
1.5.37   Thrombolytic Therapy
1.5.38   C V P Line
1.5.39   Defibrilator Shock
1.5.40   NTG/Xylocard Infusion
1.5.41   ECHO Cardiography
         Endoscopic Specialised Procedures and
         Diagnostic
         Gastroscopy (Oesophagus, stomach, deudenum)
1.5.42   (Diagnostic and Therapeutic)
1.5.43   Sigmoidoscopy and Colonoscopy
1.5.44   Bronchoscopy and Foreign Body Removal
1.5.45   Arthros copy (Diagnostic and Therapeutic)
1.5.46   Laproscopy (Diagnostic and Therapeutic)
1.5.47   Colposcopy
1.5.48   Hysteroscopy
         Psychiatry Services
1.5.49   Modified ECT
1.5.50   Narcoanalysis
         Physiotherapy Services
         With Electrical Equipments
1.5.51   Computerised Tractions (Lumbar & Cervical)
1.5.52   Short wave diathermy
1.5.53   Electrical Stimulator with TENS
1.5.54   Electrical Stimulator
1.5.55   Ultra Sonic Therapy
1.5.56   Paraffin Wax Bath
1.5.57   Infra Red Lamp (Therapy)
1.5.58   U V (Therapeutic)
1.5.59   Electric Vibrator
1.5.60   Vibrator Belt Massage
         With Mechanical Gadgets/Exercises
1.5.61   Mechanical Tractions (Lumber & Cervical)
1.5.62   Exercycle
1.5.63   Shoulder Wheel
1.5.64   Shoulder Pulley
1.5.65   Supinator Pronator Bar
1.5.66   Gripper
1.5.67   Visco Weight Cuffs
1.5.68   Walking Bars
1.5.69   Post Polio Exercise
1.5.70   Obesity Exercises
1.5.71   Cerebral Palsy – Massage
1.5.72   Breathing Exercises & Postural Drainage
         Eye Specialist Services (Opthalmology)
         OPD Procedures
1.5.73   Refraction (by using snellen’s chart)
1.5.74   Refraction (by auto refrectro meter)



                                                       63
 1.5.75   Syringing and Probing
 1.5.76   Foreign Body Removal (conjuctival)
 1.5.77   Foreign Body Removal (Corneal)
 1.5.78   Epilation
 1.5.79   Suture Removal
 1.5.80   Subconj Injection
 1.5.81   Retrobular Injection (Alcohol etc.)
 1.5.82   Tonometry
 1.5.83   Biometry / Keratometry
 1.5.84   Automated Perimetry
 1.5.85   Pterygium Excision
 1.5.86   Syringing & Probing
 1.5.87   I & C of chalazion
 1.5.88   Wart Excision
 1.5.89   Stye
 1.5.90   Cauterization (Thermal)
 1.5.91   Conjuctival Resuturing
 1.5.92   Corneal Scarping
 1.5.93   I & D Lid Abscess
 1.5.94   Uncomplicated Lid Tear
 1.5.95   Indirect Opthalmoscopy
 1.5.96   Retinoscopy
          IPD Procedures
 1.5.97   Examination under GA
 1.5.98   Canthotomy
 1.5.99   Paracentesis
1.5.100   Air Injection & Resuturing
1.5.101   Enucleation with Implant
1.5.102   Enucleaion without Implant
1.5.103   Perforating Coneo Scleral Injury Repair
1.5.104   Cataract Extraction
1.5.105   Glaucoma (Trabeculectomy)
1.5.106   Cutting of Iris Prolapse
1.5.107   Small Lid Turnour Excision
1.5.108   Conjuctival Cyst
1.5.109   Capsulotomy
1.5.110   Ant. Chamber Wash
1.5.111   Evisceration
          ENT Services
          OPD Procedures
1.5.112   Foreign Body Removal (Ear and Nose)
1.5.113   Syringing of Ear
1.5.114   Chemical Cauterization (Nose & Ear)
1.5.115   Eustachian Tube Function Test
1.5.116   Vestibular Function Test/Caloric Test
          Minor Procedures



                                                    64
        Therapeutic Removal of Granulations (Nasal,
1.5.117 Aural, Oropharynx)
1.5.118 Punch Biopsy (Oral Cavity & Oropharynx)
1.5.119 Cautrization (Oral, Oropharynx, Aural & nasal)
        Nose Surgery
1.5.120 Packing (Anterior & Posterior Nasal)
1.5.121 Antral Punchure (Unilateral & Bilateral)
1.5.122 Inter Nasal Antrostomy (nilateral & Bilateral)
1.5.123 I & D Septal Abscess (Unilateral & Bilateral)
1.5.124 S M R
1.5.125 Septoplasty
1.5.126 Fracture Reduction Nose

1.5.127 Fracture Reduction Nose with Septal Correction
        Transantral Procedures (Biopsy, Excision of
1.5.128 cyst and Angiofibroma Excision)
1.5.129 Transantral Biopsy
1.5.130 Rhinoplasty

1.5.131 Septoplasty with reduction of terbinate (SMD)
        Ear Surgery
1.5.132 Mastoid Abscess I & D
1.5.133 Mastoidectomy
1.5.134 Stapedotomy
1.5.135 Examination under Microscope
1.5.136 Myringoplasty
1.5.137 Tympanoplasty
1.5.138 Myringotomy
1.5.139 Ear Piercing
1.5.140 Hearing Aid Analysis and Selection
        Throat Surgery
1.5.141 Adenoidectomy
1.5.142 Tonsillectomy
1.5.143 Adenoidectomy + Tonsillectomy
1.5.144 Tongue Tie excision
        Endoscopic ENT Procedures
1.5.145 Direct Laryngoscopy
1.5.146 Hypopharyngoscopy
1.5.147 Direct Laryngoscopy & Biopsy
1.5.148 Broncoscopic Diagnostic
1.5.149 Broncoscopic & F B Removal
        General ENT Surgery
1.5.150 Stiching of LCW (Nose & Ear)
1.5.151 Preauricular Sinus Excision
1.5.152 Tracheostomy
        Audiometry
1.5.153 Audiogram (Pure tone and Impedence)



                                                         65
          Obstetric & Gynecology Specialist Services
1.5.154   Episiotomy
1.5.155   Forceps delivery
1.5.156   Craniotomy-Dead Fetus/Hydrocephalus
1.5.157   Caeserean section
          Female Sterilisation ( Mini Laparotomy &
1.5.158   Laparoscopic)
1.5.159   D&C
1.5.160   MTP
1.5.161   Hysterectomy
1.5.162   Bartholin Cyst Excision
1.5.163   Suturing Perimeal Tears
1.5.164   Ovarian Cystectomy / Oophrectomy
1.5.165   Vaginal Hysterectomy
1.5.166   Haematocolpes Drainage Colpotomy
1.5.167   Casserian Hystrectomy
1.5.168   Assisted Breech Delivery
1.5.169   Cervical Biopsy
1.5.170   Cervical Cautery
1.5.171   Nomal Delivery
1.5.172   Casserian
1.5.173   EUA
1.5.174   Midtrimestor Abortion
1.5.175   Ectopic Pregnancy Ruptured
1.5.176   Retain Placenta
1.5.177   Suturing Cervical Tear
1.5.178   Assisted Twin Delivery
           Dental Services
1.5.179   Dental Caries/Dental Abcess/Gingivitis
1.5.180   Periodontitis
1.5.181   Minor Surgeries, Impaction, Flap
1.5.182   Malocclusion
1.5.183   Prosthodontia (Prosthetic Treatment)
1.5.184   Trauma including Vehicular Accidents
1.5.185   Maxillo Facial Surgeries
1.5.186   Neoplasms
1.5.187   Sub Mucus Fibrosis (SMF)
1.5.188   Scaling and Polishing
1.5.189   Root Canal Treatment
1.5.190   Extractions
1.5.191   Light Cure
1.5.192   Amalgum Filling (Silver)
          Sub Luxation and Arthritis of
1.5.193   Temporomandibular Joints
1.5.194   Pre Cancerous Lesions and Leukoplakias
1.5.195   Intra oral X-ray
1.5.196   Fracture wiring
1.5.197   Apiscectomy


                                                       66
1.5.198 Gingivectomy
1.5.199 Removal of Cyst
        Complicated Extractions (including suturing of
1.5.200 gums)
         Surgical
1.5.201 Abcess drainage including breast & perianal
1.5.202 Wound Debridement
1.5.203 Appendicectomy
1.5.204 Fissurotomy or fistulectomy
1.5.205 Hemorrohoidectomy
1.5.206 Circumcision
1.5.207 Hydrocele surgery
1.5.208 Herniorraphy
1.5.209 Suprapubic Cystostomy
1.5.210 Urethral Dilatation
1.5.211 Cystoscopy
1.5.212 Endoscopy
1.5.213 Esophagoscopy
1.5.214 Diagnostic Laparoscopy
1.5.215 Colonoscopy
1.5.216 Sigmoidoscopy
1.5.217 Colposcopy
1.5.218 Hysteroscopy
1.5.219 Arthroscopy
1.5.220 Tonsillectomy
1.5.221 Mastoidectomy
1.5.222 Stapedotomy
1.5.223 Craniotomy (Neurosurgical)
1.5.224 Episiotomy
1.5.225 Forceps delivery
1.5.226 Craniotomy-Dead Fetus/Hydrocephalus
1.5.227 Caeserean section
1.5.228 Female Sterilisation ( Mini Laparotomy &
        Laparoscopic)
1.5.229 Vasectomy
1.5.230 D&C
1.5.231 MTP
1.5.232 Hysterectomy
1.5.233 FNAC
1.5.234 Total Parotidectomy
1.5.235 Intra-oral removal of submandibular duct
        Calculous
1.5.236 Excision Branchial Cyst or Fistula/sinus
1.5.237 Lingual Throid
1.5.238 Thyroid Adenoma Resection / Enucleation
1.5.239 Hemithyroidectomy (Sub total
        Thyroidectomy/Lobectomy)
1.5.240 Cysts and Benign Tumour of the Palate
1.5.241 Excision Submucous Cysts
        Breast
1.5.242 Excision fibroadenoma – Lump
1.5.243 Simple Mastectomy
1.5.244 Halstead’s Radical, Mastectomy/Patey’s
        Operation



                                                         67
1.5.245 Sectoral
        Mastectomy/Microdochectomy/Lumpectomy
1.5.246 Wadge Biopsy
1.5.247 Excision Mammary Fistula
        Hernia
1.5.248 Ingunial Hernia repair reinforcement
1.5.249 Ingunial Hernia repair with mesh
1.5.250 Femoral Hernia repair
1.5.251 Epigastric/Ventral Hernia repair
1.5.252 Recurrent Ingunial Hernia repair
1.5.253 Ventral Hernia repair with mesh
1.5.254 Strangulated Ventral or Incisional
        Hernia/Ingunial
1.5.255 Recurrent Incisional Hernia
1.5.256 Diaphargmatic Hernia
        Abdomen
1.5.257 Exploratory Laparotomy
1.5.258 Gastrostomy or Jejuncstomy
1.5.259 Simple Closure of Perforated Ulcer
1.5.260 Reamstedt’s Operation
1.5.261 Gastro-Jejunostomy
1.5.262 Vagotomy & Drainage Procedure
1.5.263 Adhesonolysis or division of bands
1.5.264 Mesenteric Cyst
1.5.265 Retroperitoneal Tumour Excision
1.5.266 Intussuception (Simple Reduction)
1.5.267 Burst Abdomen Repair
        Spleen and Portal Hypertension
1.5.268 Splenectomy
        Pancreas
1.5.269 Drainage of Pseudopancreatic Cyst
1.5.270 Retroperitoneal Drainage of Abscess
        Appendix
1.5.271 Emergency Appendisectomy
1.5.272 Interval Appendisectomy
1.5.273 Appendicular Abscess Drainage
        Small Intestine
1.5.274 Resection and Anastomosis
1.5.275 Intussusception
1.5.276 Intestinal Fistula
1.5.277 Multiple Resection and Anaestomosis
1.5.278 Intestinal Performation
        Liver
1.5.279 Open Drainage of liver abscess
1.5.280 Drainage of Subdia, Abscess/Perigastric
        Abscess
        Biliary System
1.5.281 Cholecystostomy
1.5.282 Cholecystectomy
1.5.283 Cholecystectomy and Choledocholithotomy
        Colon, Rectum and Anus
1.5.284 Fistula in ane low level
1.5.285 Fistula in ane high level
1.5.286 Perianal Abscess



                                                  68
1.5.287   Catheters
1.5.288   IV Sets
1.5.289   Colostomy Bags
1.5.290   Ischiorectal Abscess
1.5.291   Ileostomy or colostomy alone
1.5.292   Sigmoid Myotomy
1.5.293   Right Hemicolectomy
1.5.294   Sigmoid & Descending Colectomy
1.5.295   Haemorroidectomy
1.5.296   Sphincterotomy of Fissurectomy
1.5.297   Tube Caecostomy
1.5.298   Closure of loop colostomy
1.5.299   Rectal Prolapse Repair
1.5.300   Anal Sphincter Repair after injury
1.5.301   Thiersch’s operation
1.5.302   Volvulus of colon
1.5.303   Resection anastomosis
1.5.304   Imperforate anus with low opening
1.5.305   Pilonidal Sinus
1.5.306   Penis, Testes, Scrotum
1.5.307   Circumcision
1.5.308   Partial amputation of Penis
1.5.309   Total amputation of Penis
1.5.310   Orchidopexy (Unilateral & Bilateral)
1.5.311   Orchidectomy (Unilateral & Bilateral)
1.5.312   Hydrocele (Unilateral & Bilateral)
1.5.313   Excision of Multiple sebaceous cyst of scrotal
          skin
1.5.314   Reduction of Paraphimosis
          Other Procedures
1.5.315   Suture of large laceration
1.5.316   Suturing of small wounds
1.5.317   Excision of sebaceous cyst
1.5.318   Small superficial tumour
1.5.319   Large superficial tumour
1.5.320   Repair torn ear lobule each
1.5.321   Incision and drainage of abscess
1.5.322   Lymph node biopsy
1.5.323   Excision Biopsy of superficial lumps
1.5.324   Excision Biopsy of large lumps
1.5.325   Injection Haemorrhoids/Ganglion/Keloids
1.5.326   Removal of foreign body (superficial)
1.5.327   Removal of foreign body (deep)
1.5.328   Excision Biopsy of Ulcer
1.5.329   Excision Multiple Cysts
1.5.330   Muscle Biopsy
1.5.331   Tongue Tie
1.5.332   Debridment of wounds
1.5.333   Excision carbuncle
1.5.334   Ingroving Toe Nail
1.5.335   Excision Soft Tissue Tumour Muscle Group
1.5.336   Diabetic Foot Asnd carbuncle
          Urology
1.5.337   Pyelolithotomy



                                                           69
1.5.338   Nephrolithotomy
1.5.339   Simple Nephrostomy
1.5.340   Implantation of ureters Bilateral
1.5.341   Vesico-vaginal fistula
1.5.342   Nephrectomy
1.5.343   Uretrolithotomy
1.5.344   Open Prostectomy
1.5.345   Closure of Uretheral Fistula
1.5.346   Cystolithotomy Superopubic
1.5.347   Dialatition of stricture urethra under GA
1.5.348
        Dialation of stricture urethra without anaesthesia
1.5.349 Meatotomy
1.5.350 Testicular Biopsy
1.5.351 Trocar Cystostomy
        Plastic Surgery
1.5.352 Burn Dressing Small, medium (10% to 30%),
        large 30% to 60%, extensive > 60%
1.5.353 Ear lobules repair one side (bilateral)
1.5.354 Simple wound
1.5.355 Complicated wound
1.5.356 Face Scar – Simple
1.5.357 Cleft Lip – One side
1.5.358 Small wound skin graft
1.5.359 Simple injury fingers
1.5.360 Finger injury with skin graft
1.5.361 Multiple finger injury
1.5.362 Crush injury hand
1.5.363 Full thickness graft
1.5.364 Congenitial Deformity (Extra digit, Syndactly,
        Constriction brings)
1.5.365 Reconstruction of Hand (Tendon)
1.5.366 Polio Surgery
1.5.367 Surgery concerning disability with Laprosy
1.5.368 Surgery concerning with TB
        Paediatric Surgery
1.5.369 Minor Surgery, I & D, Prepuceal Dilatation,
        Meatotomy
1.5.370 Gland Bipsy, Reduction Paraphimosis, small
        soft Tissue tumour (Benign)
1.5.371 Rectal Polyp removal, deep abscess
1.5.372 Big soft tissue tumour
1.5.373 Branchial cyst/fistula/sinus
1.5.374 Ingunial Herniotomy (Unilateral & Bilateral)
1.5.375 Orchidopexy 9Unilateral & Bilateral)
1.5.376 Pyoric Stenosis Ramsteadt operation
1.5.377 Exploratory Laprotomy
1.5.378 Neonatal Intestinal Obstruction / Resection /
        Atresia
1.5.379 Gastrostomy, colostomy
1.5.380 Umbilical Hernia / Epigastric Hernia
1.5.381 Sacrocaccygeal Teratoma
1.5.382 Torsion of Testis
1.5.383 Hypospadius single stage (first stage)



                                                             70
          Orthopaedic Surgery
          Hip Surgery
1.5.384   Femoral Neck nailing with or without plating
          replacement prosthesis / Upper Femoral
          Osteotomy; Innominate Osteotomy/Open
          Reduction of Hip disclocation; DHS/Richard
          Screw Plate
1.5.385   Synovial or bone biopsy from HIP
1.5.386   Girdle stone Arthoplasty
          Fractures
1.5.387   Open reductuin int, fixation or femur, tibia, B.
          Bone, Forarm Humerus inter-condylar fracture
          of humerus and femur and open reduction and
          int. Fixation bimaleolar fracture and fracture
          dialocation of ankle montaggia fracture
          dialocation
1.5.388 Medical concyle of humerus fracture lateral
        condyle of humerus Olecranen fracture, head of
        radius lower end of radius, medial malleolus
        patella fracture and fracture of calcaneum talus
        single forearm, bone fracture
1.5.389 External Fixation Appleication Pelvis femur,
        tibia humerus forearm
1.5.390 Ext. fixation of hand & foot bones
1.5.391 Tarsals, Metatarsals, Phalanges carpals,
        Metacarples, excision head fibula, lower and of
        Inia
1.5.392 Drainage of fracture
1.5.393 Interlocking nailing of long bones
1.5.394 Debridement & Secondary closure
1.5.395
        Percutaneous Fixation (small and long bones)
        Closed Reduction
1.5.396 Hand, Foot bone and cervicle
1.5.397 Forearm or Arm, Leg, Thigh, Wrist, Aknle
1.5.398 Dislocation elbow, shoulder, Hip, Knee
1.5.399 Closed Fixation of hand / foot bone
        Open Reduction
1.5.400 Shoulder dislocation, knee dislocation
1.5.401 Acromiocalvicular or stemoclavicular Jt.
        Clavicle
1.5.402 Ankle Bimalleolar Open reduction, Ankle
        Trimalleolar open reduction
1.5.403 Wrist dislocation on intercarpal joints
1.5.404 MP & IP Joints
1.5.405 Knee Synovectomy / Menisectomy
1.5.406 Fasciotomy leg/forearm
1.5.407 High Tibial Osteotomy
1.5.408 Arthodesis (Shoulder/Knee Ankle, Triple/elbow,
        Wrist/Hip)
1.5.409 Arthodesis – MP & IP Joints
1.5.410 Excision Exostosis long bones, single / two
1.5.411 Currentage Bone Grafting of Bone Tumour of
        fumur/tibia Humerus & forearm


                                                             71
1.5.412
          Surgery tumours of small bone hand and foot
1.5.413
        Debridement primary closure of compounds
        fracture of tibia, femur forearm without fixation
1.5.414 Debridement of hand/foot
1.5.415 Debridement primary closure of compound
        fractures of tibia, femur forearm with fixation
1.5.416
        Tendon surgery soft tissue release in club foot
1.5.417 Internal fixation of small bone (Single, Two ,
        More than two)
1.5.418 Tendon Surgery (Repair and Lengthening)
1.5.419 Surgery of chronic Osteomlitis
        (Saucerization,Sequentrectomy of femur,
        Humerus, Tibia)
1.5.420 Fibula Radius Ulna (Clavicle) and Wrist, Ankle,
        Hand foot
1.5.421 Amputation (Thigh or arm, leg or forearm, feet
        or hand, digits)
1.5.422 Disarticulation of hip or shoulder
        (Disarticulation of knee elbow/wrist/ankle; Fore-
        quarter or hind-quarter)
1.5.423 POP Aplication (Hip Spica, Shoulde spica POP
        Jacket; A-K/A-E POP; B-K/B-E POP)
1.5.424 Corrective Osteotomy of long bones
1.5.425 Excision Arthoplasty of elbow & other major
        joints; Excision Arthoplasty of small joints
1.5.426 Operation of hallus valgus
1.5.427 Bone Surgery (Needle biopsy, Axial Skelton,
        Non-Axial)
1.5.428 Removal K Nail AO Plates
1.5.429 Removal Forearm Nail, Screw, Wires
1.5.430 Skeltal Traction Femur, Tibia, Calcanlum,
        Elbow
1.5.431 Bone Grafting (small grafting and long bone)
1.5.432 Ingrowing toe-nail
1.5.433 Soft tissue Biopsy
1.5.434 Skin Graft (small, medium and large)
1.5.435 Patellectomy
1.5.436 Olacranon fixation
1.5.437
        Open Ligament repair of elbow, Ankle & Wrist
1.5.438 Arthrotomy of hip/shoulder/elbow
1.5.439 Carpal Tunnel Release
1.5.440 Dupuytrens contracture
1.5.441 Synovectomy of major joint shoulder/hip/
        Elbow
1.5.442 Repair of ligaments of knee
1.5.443 Closed Nailing of long bones
1.5.444 External fixator readjustment dynamisation
        removal of external fixation/removal of implant
1.5.445 Excision of soft tissue tumour muscle group




                                                            72
II. Physical Infrastructure
                                                                    Current Availability in the Hospital   Remarks
           2.1. Size (Area) of the Hospital (In Sq. Meters)
           2.2. Number of indoor beds available
Location
          2.3. Is the hospital located near residential area?
               (Yes / No)
          2.4. Is the hospital building free from danger of
               flooding? (Yes / No)
          2.5. Is the hospital located in an area free from
               pollution of any kind including air, noice, water
               and land pollution? (Yes /No)
          2.6. Is necessary environmental clearance obtained?
               (Yes / No)
          2.7.
               Whether hospital building is diabled friendly as
               per provisions of Disability Act? (Yes / No)
Building Status
          2.8. What is the present stage of construction of the
               building (Complete: 1; Incomplete: 0)
          2.9. Compound Wall / Fencing (1-All around; 2-
                Partial; 3-None)
         2.10. Condition of plaster on walls (1- Well plastered
                with plaster intact every where; 2- Plaster
                coming off in some places; 3- Plaster coming off
                in many places or no plaster)
         2.11. Condition of floor (1- Floor in good condition; 2-
                Floor coming off in some places; 3- Floor
                coming off in many places or no proper
                flooring)
Building Requirements (Availability to be recorded in Yes / No)
         2.12. Administrative Block
         2.13. Circulation Area
         2.14. Entrance Area
         2.15. Ambulatory Care Area (OPD)
         2.16. Waiting Spaces adjacent to each consultation
                and treatment room
         2.17. Registration Counter
         2.18. Assistance and Enquiry Counter
         2.19. Departments / Clinics
            a. General
            b. Medical
            c. Surgical
            d. Ophthalmic
            e. ENT
             f. Dental
            g. Obstetric & Gynaecologist
            h. Paediatrics
             i. Dermatology & Venereology
             j. Psychiatry
            k. Neonatology
             l. Orthopaedic
            m. Social Service



                                                                                                                     73
   n.
         Infectious & Communicable Diseases located in
         remote corner with independent access
   o.    National Health Programmes
2.20.    Nursing Stations
2.21.    Diagnostic Services
   a.    X-Ray Room
   b.    Dark Room for X-Ray film developing and
         processing
   c.    X-Ray Reporting Room for Doctor
   d.    Is X-Ray room accessible to OPD, Wards and
         Operation Theatre?(Yes / No)
   e.    Ultrasound Room
   f.    Is Ultrasound room accessible to OPD, Wards
         and Operation Theatre?(Yes / No)
   g.    Ultrasound Reporting room for Doctors
2.22.    Clinical Laboratory
   a.    Fully equipped laboratory
   b.    Sample Collection Room with facility for quick
         diagnosis of blood, urine, etc.
   c.    Separate reporting room for Doctors
2.23.    Blood Bank
   a.    Fully equipped Blood Bank
   b.
         Is the blood bank located in close proximity to
         pathology department and at an accessible
         distance to Operation Theatre, ICU, Emergency
         and Accident department? (Yes / No)
   c.    Separate reporting room for Doctors
2.24.    Intermediate Care Area (Inpatient Nursing Units)
   a.    General Wards (Number to be given)
    i.   Male
   ii.   Female
  iii.   Total
   b.    Private Wards (Number to be given)
   c.    Wards for Specialities (Number to be given)
   d.    Nursing Stations (Number to be given)
   e.    Doctors' Duty Room
    f.   Pantry
   g.    Isolation Room
   h.    Treatment Room
     i   Nursing Store
    j.   Toilets
2.25.    Pharmacy (Dispensary)
   a.    Medical Store facility for indoor patients
         Separate pharmacy with accessibility for OPD
   b.    patients
2.26.    Intensive Care Unit (ICU) & High Dependency Wards
   a.    Number of beds available in ICU
         Number of beds available in High Dependency
   b.    Wards


                                                             74
    c. Changing Room
        Is the unit located close to OT, X-Ray and
    d. Pathology department? (Yes / No)
    e. Essential Specialised Services
     i.       Piped Suction
    ii.       Medical Gases
  iii.        Uninterrupted Electric Supply
   iv.        Heating
    v.        Ventilation
   vi.        Central Air Conditioning
     f. Nurses' Station
    g. Clean Utility Area
    h. Equipment Room
2.27. Critical Care Area (Emergency Services)
    a. Critical Care Area with independent entry
    b. Adequate space for free passage of vehicles
    c. Covered area for alighting patients
2.28. Operation Theatre
    a. Fully equipped Operation Theatre
        Location of OT in close relation to ICU,
    b. Radiology, Pathology, Blood Bank
    c. Specialized Services in OT
     i. Piped suction and medical gases
    ii. Uninterrupted Electric Supply
  iii. Heating
   iv. Air Conditioning
    v. Ventilation
   vi.      Efficient Life Service
    d. Other Rooms adjoining OT
     i.     Preparation Room
    ii. Pre-operative Room
  iii. Post-operative Room
   iv. Scrub-up Room for washing and scrubbing
    v. Sub-sterilizing Unit
2.29. Delivery Suit Unit
    a. Fully equipped Delivery Suit Unit located near
        OT
    b. Facilities in Delivery Suit Unit
     i. Reception and admission
    ii. Examination and Preparation Room
  iii. Labour Room (clean and a septic room)
   iv. Delivery Room
    v. Neo-natal Room
   vi. Sterilizing Rooms
  vii. Sterile Store Room
 viii. Scrubbing Room
   ix. Dirty Utility
2.30. Physiotherapy
    a. Physiotherapy department located at a
        convenient access to both outdoor and indoor
        patients
    b. Facilities
     i. Physical and electro-therapy rooms
    ii. Gymnasium
  iii. Office



                                                        75
  iv. Store
   v. Separate toilets for male and female
2.31. Hospital Services
   a. Hospital Kitchen (Diatary Service)
   b.
      Central Sterile and Supply Department (CSSD)
    i. CSSD located
   ii. Easily accessible to OT
  iii. Provision of hot water supply
   c. Hospital Laundry
   d. Medical and General Stores
   e. Mortuary
2.32. Engineering Services
   a. Electric Engineering
    i. Electirc Sub Station and standby generator
      room
   ii. Emergency Lighting (shadowless light in OT
      and Delivery Rooms and portable light units in
      Wards and Departments
  iii. Call Bells
  iv. Ventilation (Natural or mechanical exhaust)

   b. Mechanical Engineering
    i. AC and Room Heating in OT and Neo-natal
   ii. Air coolers or hot air convectors
  iii. Water coolers and Refrigerators
   c. Public Health Engineering
    i. Water Supply
    1        Round the clock pipoed water supply
    2        Overhead water storage tank with
             pumping and boosting arrangements
    3        Separate provision for fire fighting and
             water softening plants
   ii. Drainage and Sanitation
       Proper drainage and sanitation system for waste
       water, surface water, sub soil water and
       sewerage
  iii. Waste Disposal System
       Proper waste disposal system as per National
       Guidelines
  iv. Trauma Centre
   d. Fire Protection
   e. Telephone and Intercom
    f. Medical Gas
   g. Cooking Gas
   h. Laboratory Gas
    i. Office-cum-store for maintenance work
    j. Parking place
   k. Administrative Services
    i.    General Section
   ii.    Medical Records Section
    l. Committee Room
  m. Residential Quarters for all medical and para
       medical staff




                                                         76
III. Manpower
      A.        Doctors
                                                                                               Current
                                                                                            Availability at   Remarks /
   S.No.                            Personnel                                IPHS Norm        Hospital       Suggestions /
                                                                                              (Indicate     Identified Gaps
                                                                                             Numbers)
      1         Hospital Superintendent                                            1
      2         Medical Specialist                                                 3
      3         Surgery Specialists                                                2
      4         O&G specialist                                                     4
      5         Psychiatrist                                                       1
      6         Dermatologist / Venereologist                                      1
      7         Paediatrician                                                      2
      8         Anesthetist (Regular / trained)                                    2
      9         ENT Surgeon                                                        1
      10        Opthalmologist                                                     1
      11        Orthopedician                                                      1
      12        Radiologist                                                        1
      13        Microbiologist                                                     1
      14        Casualty Doctors / General Duty Doctors                            6
      15        Dental Surgeon                                                     1
      16        Forensic Expert                                                    1
                                        1
      17        Public Health Manager                                              1
                                    2
      18        AYUSH Physician                                                    2
      19        Pathologists                                                       2
                Total                                                             34
  1
      May be a Public Health Specialist or management specialist trained in public health
  2
      Provided there is no AYUSH hospital / dispensary in the district headquarter
      B.        Para-Medicals
                                                                                               Current
                                                                                            Availability at   Remarks /
   S.No.                            Personnel                                IPHS Norm        Hospital       Suggestions /
                                                                                              (Indicate     Identified Gaps
                                                                                             Numbers)
      1         Staff Nurse*                                                   75 to 100
      2         Hospital worker (OP/ward +OT+ blood bank)                          20
      3         Sanitary Worker                                                    15
      4         Ophthalmic Assistant / Refractionist                                1
      5         Social Worker / Counsellor                                          1
      6         Cytotechnician                                                      1
      7         ECG Technician                                                      1
      8         ECHO Technician                                                     1
      9         Audiometrician
      10        Laboratory Technician ( Lab + Blood Bank)                         12
      11        Laboratory Attendant (Hospital Worker)                             4
      12        Dietician                                                          1


                                                                                                                        77
         13        PFT Technician                                                       -
         14        Maternity assistant (ANM)                                            6
         15        Radiographer                                                         2
         16        Dark Room Assistant                                                  1
         17        Pharmacist
                              1
                                                                                        5
         18        Matron                                                               1
         19        Assistant Matron                                                     2
         20        Physiotherapist                                                      1
         21        Statistical Assistant                                                1
         22        Medical Records Officer / Technician                                 1
         23        Electrician                                                          1
         24        Plumber                                                              1
*
    1 Staff Nurse for every eight beds with 25% reserve
1
    One may be from AYUSH

         C.        Administrative Staff
                                                                                                             Current
                                                                                                          Availability at   Remarks /
       S.No.                           Personnel                                  IPHS Norm                 Hospital       Suggestions /
                                                                                                            (Indicate     Identified Gaps
                                                                                                           Numbers)
                   Manager (Administration)                                             -
                   Junior Administrative Officer                                        1
                   Office Superintendent                                                1
                   Assistant                                                            2
                   Junior Assistant / Typist                                            2
                   Accountant                                                           2
                   Record Clerk                                                         1
                   Office Assistant                                                     1
                   Computer Operator                                                    1
                   Driver                                                               2
                   Peon                                                                 2
                   Security Staff*                                                      2
                   Total                                                               17

Note: Drivers post will be in the ratio of 1 Driver per 1 vehicle . Driver will not be required if outsourced
* The number would vary as per requirement and to be outsourced.
         D.        Operation Theatre
                                                                                                   Current
       S.No.                               Staff                                  IPHS Norm     Availability at   Remarks /
                                                                                                  Hospital       Suggestions /
                                                                         Emergency /              (Indicate     Identified Gaps
                                                                                     General OT  Numbers)
                                                                          FW OT
         1         Staff Nurse                                               8           1
         2         OT Assistant                                              4           2
         3         Sweeper                                                   3           1
                   Total                                                     15          4



                                                                                                                                      78
    E.              Blood Bank / Blood Storage

                                                                                                 Current
   S.No.                                 Staff                              IPHS Norm         Availability at   Remarks /
                                                                                                Hospital       Suggestions /
                                                                                                (Indicate     Identified Gaps
                                                                                    Blood      Numbers)
                                                                   Blood Bank
                                                                                   Storage
     1              Staff Nurse                                         3             1
     2              MNA / FNA                                           1             1
     3              Lab Technician                                      1             -
     4              Safai Karamchari                                    1             1
                    Total                                               6             3

IV. Investigative & Laboratory Services

                                                                    Current Availability at
                                                                                                  Remarks / Suggestions /
   S. No.               Speciality / Diagnostic Services / Tests          Hospital
                                                                                                     Identified Gaps
                                                                         (Yes / No)
    4.1.            CLINICAL PATHOLOGY
     a.             Haematology
               i.   Haemoglobin estimation
              ii.   Total Leucocyte count
             iii.   Differential Leucocyte count
             iv.    Absolute Eosinophil count
              v.    Reticulocyte count
             vi.    Total RBC count
            vii.    E.S.R.
           viii.    Bleeding time
             ix.    Clotting time
              x.    Prothrombin time
             xi.    Peripheral Blood Smear
            xii.    Malaria/Filaria Parasite
           xiii.    Platelet count
            xiv.    Packed Cell volume
             xv.    Blood grouping
            xvi.    Rh typing
            xvii    Blood Cross matching
           xviii    ELISA for HIV, HBS AG,       and HCV
     b.             Urine Analysis
               i.   Urine for Albumin
              ii.   Sugar
             iii.   Deposits
             iv.    bile salts
              v.    bile pigments



                                                                                                                            79
      vi. acetone
     vii. specific gravity
    viii. Reaction (pH)
 c.       Stool Analysis
         i. Stool for Ova cyst (Eh)
        ii. Culture and Sensitivity
       iii. Hanging drop for V. Cholera
       iv. Occultblood
        d. Semen Analysis (morphology, count)
            CSF Analysis (Cell count, culture sensitivity
        e.
            etc., gram staining
         f. Aspirated fluids (cell count cytology)
4.2.        PATHOLOGY
 a.         PAP smear
         i. Cytology
 b.         Sputum
         i. Sputum cytology
 c.         Haematology
          i Bone Marrow Aspiration
         ii Coagulation disorders
       iii. Sickle cell anaemia
       iv. Thalassemia
 d.         Histopathology
         i. All types of specimens, Biopsies
4.3.        MICROBIOLOGY
            Smear for AFB (Acid Fast Bacilli), KLB
         i.
            (Diphtheria Bacilli)
            Culture and sensitivity for blood, sputum,pus,
        ii.
            urine etc.
       iii. Stool culture for enteco pathogene
            Supply of different Specimen collection and
       iv. transportation      media for peripheral
              Laboratories
         v KOH Study for Fungus
        vi Grams Stain for Throat swab, sputum etc.

                                                      S
              Bacteriological analysis of water by Rapid H2
       vii test to be done in districts where there is
           no separate public health laboratory
4.4.        SEROLOGY
         i. Pregnancy test (Urine gravindex)
        ii. Coomb's tests,
       iii. Lepto spirosis (Rapid test / ELISA)
       iv.  WIDAL test
         v  RPR test
        vi  Elisa test for HIV, HBs Ag, HCV
       vii  RA factor test
4.5.        BIOCHEMISTRY
         i. Blood Sugar
        ii. Glucose Tolerance Test



                                                              80
         iii.    Glycosylated Hemoglobin
          iv.    Blood urea, blood cholesterol
           v.    Serum bilirubin
          vi.    Liver function tests
         vii.    Kidney function tests
        viii.    Lipid Profile
          ix.    Blood uric acid
            x    Serum calcium, sodium, potassium
           xi    Serum Phosphorous
          xii    Serum Magnesium
        xiii.    CSF for protein, sugar
        xiv.     Blood gas analysis
                 Estimation of residual chrorine in water by OT
          xv
                 test
          xvi    Thyroid T3 T4 TSH
         xvii    CPK
        xviii    Chloride
4.6.             CARDIAC INVESTIGATIONS
            i.   ECG
            ii   Stress
          iii.   ECHO
4.7.             OPHTHALMOLOGY
            i.   Refraction by using Snellen's chart
           ii.   Retinoscopy
          iii.   Ophthalmoscopy
4.8.             ENT
            i.   Audiometry
           ii.   Endoscopy for ENT
4.9.             RADIOLOGY
            i. Xray for Chest, Skull, Spine, Abdomen, bones
           ii.   IITB X-Ray – CR Digital
          iii.   OPG
          iv.    HSG
            v    Ultrasonography Colour Doppler
           vi    Spiral CT scan
          vii    MRI 0.5 TESSLA
4.10.            Endoscopy
           i.    Oesophagus
          ii.    Stomach
         iii.    Colonoscopy
         iv.     Bronchuscopy
           v     Arthros copy
          vi     Laparoscopy (Diagnostic)
         vii     Colposcopy
        viii.    Hysteroscopy
4.11.            Physiology (Pulmonary function test)
            i.   Pulmonary function tests




                                                                  81
V. Capacity Building
                Whether medical and paramedical staff
           5.1. undergoing Continuing Medical Education
                (CME) at intervals? (Yes / No)
                Whether medical and paramedical staff working
                in the institutions below sub-district level
           5.2. provided training such as Skill Birth Attendant
                and other skill development / management
                training? (Yes / No)

VI (A). Equipment & Furniture (As per list in IPHS)

                                                                                                         Remarks / Suggestions /
 Equipment                                   Available                                 Functional
                                                                                                            Identified Gaps




VI (B). Drugs (As per drug list in IPHS)

                                                                                                         Remarks / Suggestions /
   Drug                                              Available
                                                                                                            Identified Gaps




VII. Quality Control
   S.No.                           Particular                           Whether functional / available as per norms    Remarks
    7.1.       Citizen's charter (Yes/No)
               Constitution of Rogi Kalyan Samiti (Yes/No) (give a
    7.2.
               list of office order notifying the members)

               Internal monitoring (Social audit through Panchayati
               Raj Institution / Rogi Kalyan Samitis, medical audit,
    7.3.       technical audit, economic audit, disaster preparedness
               audit, monitoring of accessibility and equity issues,
               information exchange etc. (Specify)
               External monitoring (Monitoring by PRI (Zila
    7.4.       Parishad)/ Rogi Kalyan Samitis, service /
               performance evaluation by independent agencies
    7.5.       Monitoring of Laboratory (Internal & External
               Quality Assessment Scheme
    7.6.       Record Maintenance (Use of computers with
               connectivity to District Health System, State and
               National Level




                                                                                                                                   82
                                          Infrastructure District Hospital                        Annexure - VI
Name of the District ______________


            SN                              Facility                         Required Available     Gap
            1    Population covered (in numbers)

            2    Specialist services available (Yes/No)

            3    General Medicine

            4    General Surgery

            5    Obstetric & Gynecology

            6    Pediatrics including Neonatology

            7    Emergency (Accident & other emergency) (Casualty)

            8    Critical Care (ICU)

            9    Anesthesia

            10 Ophthalmology

            11 ENT

            12 Dermatology and Venereology (Skin & VD) RTI / STI

            13 Orthopedics

            14 Radiology

            15 Dental Care

            16 Public Health Management

            17 Para Clinical Services (Yes / No)

            18 Laboratory

            19 X-Ray

            20 Ultrasound

            21 ECG

            22 Blood Transfusion and Storage

            23 Physiotherapy




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                                        Infrastructure District Hospital                                Annexure - VI
Name of the District ______________


            SN                              Facility                               Required Available     Gap
            24 Dental Technology (Dental Hygiene)

            25 Drugs and Pharmacy

            26 What is the present stage of construction of the building
               (Complete: Yes; Incomplete: 0)
            27 Compound Wall / Fencing (Yes-All around; 2-Partial; 3-None)

            28 Condition of plaster on walls (Yes- Well plastered with plaster
               intact every where; 2- Plaster coming off in some places; 3-
               Plaster coming off in many places or no plaster)
            29 Condition of floor (Yes- Floor in good condition; 2- Floor coming
               off in some places; 3- Floor coming off in many places or no
               proper flooring)
            30 Administrative Block

            31 Circulation Area

            32 Entrance Area

            33 Ambulatory Care Area (OPD)

            34 Waiting Spaces adjacent to each consultation and treatment
               room
            35 Registration Counter

            36 Assistance and Enquiry Counter

            37 Departments / Clinics

            38 General

            39 Medical

            40 Surgical

            41 Ophthalmic

            42 ENT

            43 Dental

            44 Obstetric & Gynecologist

            45 Pediatrics




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                                        Infrastructure District Hospital                          Annexure - VI
Name of the District ______________


            SN                             Facility                          Required Available     Gap
            46 Dermatology & Venereology

            47 Psychiatry

            48 Neonatology

            49 Orthopedic

            50 Social Service

            51 Infectious & Communicable Diseases located in remote corner
               with independent access
            52 National Health Programmes

            53 Nursing Stations

            54 Diagnostic Services

            55 X-Ray Room

            56 Dark Room for X-Ray film developing and processing

            57 X-Ray Reporting Room for Doctor

            58 Is X-Ray room accessible to OPD, Wards and Operation
               Theatre?(Yes / No)
            59 Ultrasound Room

            60 Is Ultrasound room accessible to OPD, Wards and Operation
               Theatre?(Yes / No)
            61 Ultrasound Reporting room for Doctors

            62 Clinical Laboratory

            63 Fully equipped laboratory

            64 Sample Collection Room with facility for quick diagnosis of
               blood, urine, etc.
            65 Separate reporting room for Doctors

            66 Blood Bank

            67 Fully equipped Blood Bank




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                                       Infrastructure District Hospital                              Annexure - VI
Name of the District ______________


            SN                            Facility                              Required Available     Gap
            68 Is the blood bank located in close proximity to pathology
               department and at an accessible distance to Operation Theatre,
               ICU, Emergency and Accident department? (Yes / No)


            69 Separate reporting room for Doctors

            70 Intermediate Care Area (Inpatient Nursing Units)

            71 General Wards

            72 Male

            73 Female

            74 Private Wards

            75 Nursing Stations

            76 Doctors' Duty Room

            77 Pantry

            78 Isolation Room

            79 Treatment Room

            80 Nursing Store

            81 Toilets




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                                          Manpower in District Hospital                        Annexure - VI
Name of the District _______________


        SN                         Name of Staff                    Required Available   Gap
                                                    Medical Staff
         1   Hospital Superintendent
         2   Medical Specialist
         3   Surgery Specialists
         4   O&G specialist
         5   Psychiatrist
         6   Dermatologist / Venereologist
         7   Pediatrician
         8   Anesthetist (Regular / trained)
         9   ENT Surgeon
        10   Ophthalmologist
        11   Orthopedician
        12   Radiologist
        13   Microbiologist
        14   Casualty Doctors / General Duty Doctors
        15   Dental Surgeon
        16   Forensic Expert
        17   Public Health Manager1
        18   AYUSH Physician2
        19   Pathologists

                              Para Medical Staff
        20   Staff Nurse*
        21   Hospital worker (OP/ward +OT+ blood bank)
        22   Sanitary Worker
        23   Ophthalmic Assistant / Refractionist
        24   Social Worker / Counsellor
        25   Cytotechnician
        26   ECG Technician
        27   ECHO Technician
        28   Audiometrician
        29   Laboratory Technician ( Lab + Blood Bank)
        30   Laboratory Attendant (Hospital Worker)
        31   Dietician
        32   PFT Technician




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                                             Manpower in District Hospital                    Annexure - VI
Name of the District _______________


        SN                           Name of Staff                 Required Available   Gap
        33   Maternity assistant (ANM)
        34   Radiographer
        35   Dark Room Assistant
        36   Pharmacist1
        37   Matron
        38   Assistant Matron
        39   Physiotherapist
        40   Statistical Assistant
        41   Medical Records Officer / Technician
        42   Electrician
        43   Plumber

                            Administrative Staff
        44   Manager (Administration)
        45   Junior Administrative Officer
        46   Office Superintendent
        47   Assistant
        48   Junior Assistant / Typist
        49   Accountant
        50   Record Clerk
        51   Office Assistant
        52   Computer Operator
        53   Driver
        54   Peon
        55   Security Staff*

                           Operation Theatre Staff
        56   Staff Nurse
        57   OT Assistant
        58   Sweeper

                            Blood Storage Staff
        59   Staff Nurse
        60   MNA / FNA
        61   Blood Bank Technician
        62   Sweeper




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