GOVERNMENT OF THE PUNJAB

HEALTH DEPARTMENT

PROFORMA FOR THQ AND DHQ INSPECTION

Chief Minister's Monitoring Force

(Only use blue ball pen to fill the form)

Name of THQ/DHQ------HMIS Code:------

NA No.:------PP.No.:------Tehsil: ------

District ------

Name of MS of the THQ/DHQ------BS------Qualification------

Mobile # ------Phone # (with code)------

HEAD OF INSTITUTION / SCHOOL

Name of District Monitoring Officer------

Date & Time of arrival for Inspection:------

Date & Time of departure------Ref No.------

I.CLEANLINESS AND GENERAL OUTLOOK OF THE FACILITY

Sr #

/

Location

/

Good

/ Average / Poor / Non Existing
1 /

Approach Road

/
2 / Boundary Wall
3 / Lawns
4 / Internal Pathways
5 / Building
6 / Offices
7. / Waiting Area
8. / Toilets
9. / Wards
10. / Operation Theaters
11. / Labour Room
12. / Laboratory
13. / Residential Area
14. / General Impression

Remarks

II.DISPLAYS

ITEMS / Yes / No
Internal Signboards/Direction Board
Display in the Medical Suptd. Office
·  Organogram
·  Map of Distt. / Tehsil.
·  Statistics of the District / Tehsil
·  Monthly Report
·  No. of visits of OPD during last month
·  No. of Indoor patients during last month
·  No. of Deliveries conducted during last month
·  Upto date Vacancy Position
·  Slogan of the Day

Remarks

III. AVAILABILITY OF UTILITIES

Name of Utility / No / Yes
Functioning / Non Functioning
Electricity
Telephone
Sui Gas
Water supply system
Sewerage

Remarks

lV. DISPOSAL OF HOSPITAL WASTE

Sr # / Mode / Yes / No
1 / Lying open
2 / Burned by (a) Incinerator
(b) Other means
3 / Buried
4 / Carried away by municipality
5 / Any other

CHOL COUNCIL

Remarks

V. PURCHI FEES

Fees deposited till the last calendar month ------

Vl. ATTENDANCE OF DOCTORS

(From Attendance & Movement Registers)

Sr # / Designation / S / F / V / Attendance Status at the time of visit
P / UA / L / OD / SL / LC / GD
1 / Administrators
2 / Specialists
3 / MOs / WMOs
4 / Dental Surgeons

Present (P).Unauthorized absence (UA), Sanctioned leave (L).On official duty outside the Facility (OD), Short leave (SL). Doctor coming after the arrival of Monitoring Officer will be treated late comer (L C). General Duty (GD)

Remarks

VII. DETAIL OF ABSENT DOCTORS

(From Attendance & Movement Registers)

Sr
# / Design / Name / Attendance Status at the time of visit / Days of absence for last three months
P / UA / L / OD / SL / LC / GD
1
2
3
4
5
6
7
8
9

Use extra sheet if required

Remarks

VIlI. DETAIL OF ABSENT STAFF (OTHER THAN DOCTORS)

(From Attendance & Movement Registers)

Sr # / Design / Name / Attendance Status at the time of visit / Days of absence for last three months
1 / P / UA / L / OD / SL / LC / GD
2
3
4
5
6
7
8
9
10

Use extra sheet if required

Remarks

IX. DETAIL OF DOCTORS / STAFF WORKING ON GENERAL DUTY

Sr. No. / Designation / Name / Period
Years / Months / Days

X. VACANT POSTS

s.# / Name of Post / Since Vacant / Sr # / Name of Post / Since Vacant
Month / Year / Month / Years
1 / 2
3 / 4
5 / 6
7 / 8
9 / 10
11 / 12
13 / 14
15 / 16
17 / 18
19 / 20
21 / 22
23 / 24
25 / 26
27 / 28
29 / 30
31 / 32
33 / 34
35 / 36

Remarks

XI. INSPECTION OF THE FACILITY

(From Inspection Register)

Inspecting Officer / Provl. Officers / DCO or his
Representative / EDO (H) / Any other
No of inspections made during the last month

Remarks

XII. AVAILABILITY OF MEDICINES

(From Medicine Stock Register)

Sl / Medicine / Yes * / No / Sl / Medicine / Yes * / No
1 / Antibiotic Tab. / 16 / Inj. Valume
2 / Antibiotic Syrup. / 17 / Inj. ARV
3. / Antibiotic Capsules / 18 / Inj. Anti Snake venom
4 / Antibiotic Injections / 19 / Inj. Atropin
5 / ORS / 20 / Inj. TT
6 / Disposable Syringes / 21 / Anti Hypertensive Tab.
7 / Inj. Steroid Inj. / 22 / Chloroquine Tab
8 / Inj. Antitamine / 23 / Anti-histamine Tab.
9 / Inj. Adrenalin / 24 / Analgesic Tab.
10 / Anti-emetic Inj. / 25 / Iron Tab.
11 / Inj, Mannitol 20% / 26 / Contraceptive Pills
12 / Anagesic Inj. / 27 / Flajyl Tab.
13 / Dextro 5% (1000cc) / 28 / Oral Hypoglycimic Tab.
14 / Dextrose Saline (1000 cc) / 29 / Anti-epileptic Tab
15 / Haemacele / 30 / Anti TB Drugs

*Medicine physically available on the date of visit in the stock & as per Medicines Stock Register.

Remarks

XIlI. A. PATIENTS RECORD

Out Door/In Door patient’s record from every sub department

S. No. / Category / No. of Clients at the time of visits / No. of Clients during previous month
Out Patients / In Door / Out Patients / In Door
1 / Total No. of patients
2 / Medical Department
3 / Surgical Department
4 / Gynae and Obs
5 / Paediatrics
6 / Eye
7 / ENT
8 / Orthopaedics
9 / Cardiology
10 / Dental
11 / Physiotherapy
12 / X-Rays
13 / Ultrasounds
14 / Laboratory Tests
15 / Emergency Patients
16 / Medico legal Cases
17 / No. of Delivery Conducted
18 / Blood Transfusions
19 / Any Other Speciality
20 / No. of Children vaccinated against BCG
21 / No. of Children vaccinated against Routine Immunization
22 / No. of TB Patients

Remarks

XIV. EMERGENCY DEPARTMENT

A. Inspection

Category / Yes / No
Cleanness and General Out Look
Presence of Doctor
Presence of Staff
Availability of Medicines
Blood Transfusion Services
Function of Equipment
·  Oxygen Cylinder with regulator
·  Sucker
·  ECG
·  X-Ray
·  Defibrillator

B. Record

Category / Nos. of Patients at the time of visit / No. of patients during previous month
Total No. of Emergency patients
Total No. of Medico-legal cases
Total No. of Death
No. of Maternal death.
Total No. of Death excluding maternal deaths

XV AVAILABILITY OF STAFF AT EVENING & NIGH SHIFTS

Designation / Available Nos. in evening shift / Available Nos. in night shift / Remarks on the basis of indoor patients’ opinion or Monitoring Officer’s own observations regarding indoor services
Specialists on Call
Medical Officer
Nurses

Remarks

XVl. PUBLIC OPINION

No of persons contacted / Public Opinion*
Good / Satisfactory / Unsatisfactory
Presence of Doctors
Attitude of doctors towards patients
Availability of medicines
Quality of Medicines

No of persons who were satisfied or un-satisfied, out of the persons contacted, to be entered in the relevant column. The persons contacted should be those who utilized the facility any time during the last 6 months**

Remarks

XVII. DEVELOPM ENT SCHEMES/PROVISION OF MISSING FACILITIES

Missing Facilities / Funds Provided by / Status of Work / Quality / Observations
(Use extra page if required)
PHSRP / District Govt. / Not Started / Halted / % Completed / Poor / Avg. / Good
Building Hospital (New)
Building Hospital (Repair)
Residences (New)
Residences
(Repair)
Boundary wall
Electricity
Drinking Water
Latrine/Toilet
Furniture
Telephone
Sui Gas
Sewerage
Other

Remarks

XVIII. EQUIPMENT

Sr. No. / Name of Item / Availability (Nos.) / Working Condition / Remarks
Yes / No / Functional / Repairable / Unserviceable
1 / Ambulance
2 / X-Ray
3 / Dental Unit
4 / Dental X-Ray
5 / ECG Machine
6 / Hot Air Over
7 / Auto Clave (Steam Sterilizer)
8 / Ultrasound
9 / O.T. Ceiling Light.
10 / O.T. Table
11 / General Surgery Instrument Set
12 / Obstetric Instrument Set
13 / Air-conditioner for Operation Theatre
14 / Fetal Heart Detector
15 / Computer
16 / Anesthesia Machine
17 / Incubator
18 / Oxygen Cylinders
19 / Suckers
20 / Generator
21 / Nebulizer
22 / Ambu-bag
23 / Laryngoscoper

Time of Departure from the facility

Certified that this THQ/DHQ Hospital was inspected by the undersigned DMO today and the information stated above is as per facts and record.

Signatures of Medical Superintendent Signatures of DMO