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Proforma for IPHS Facility Survey of Category II (201-300 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
i Nephrology
ii Cardiology
iii Pulmunory Medicine
b. General Surgery
i Urology
ii Plastic 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 services
b. X-ray facility
c. CT Scan services
d. Sonography (Ultrasound)
e. ECG
f. EEG
g. Echocardiogram

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h. Pathology
i. Blood Bank
j. Physiotherapy
k. Dental Technology (Dental Hygiene)
l. Drugs and Pharmacy
1.4. (a) Support Services (Yes / No)
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

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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 T M T
1.5.36 Holter
1.5.37 Thrombolytic Therapy
1.5.38 C V P Line
1.5.39 Defibrilator Shock

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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)
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.)

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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
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

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1.5.126 Fracture Reduction Nose

1.5.127 Fracture Reduction Nose with Septal Correction


Transantral Procedures (Biopsy, Excision of cyst
1.5.128 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)
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

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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 E U A
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
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

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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
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

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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
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

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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
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

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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)
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

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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
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

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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

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

13
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)

14
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

15
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
AC and Room Heating in OT and Neo-natal
i. units
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

16
Current
Remarks /
Availability at
Suggestions /
S.No. Personnel IPHS Norm Hospital
Identified
(Indicate
Gaps
Numbers)
1 Hospital Superintendent 1
2 Medical Specialist 3
3 Surgery Specialists 3
4 O&G specialist 6
5 Psychiatrist 1
6 Dermatologist / Venereologist 1
7 Paediatrician 3
8 Anesthetist (Regular / trained) 6
9 ENT Surgeon 2
10 Opthalmologist 2
11 Orthopedician 2
12 Radiologist 1
Recruited in
Integrated
13 Microbiologist 1 Disease
Surveillance
Programme
14 Casualty Doctors / General Duty Doctors 20
15 Dental Surgeon 1
16 Forensic Expert 1
17 Public Health Manager1 1
18 AYUSH Physician 2
4
19 Pathologists 2
Total 61
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
Remarks /
Availability at
Suggestions /
S.No. Personnel IPHS Norm Hospital
Identified
(Indicate
Gaps
Numbers)
1 Staff Nurse* 100
2 Hospital worker (OP/ward +OT+ blood bank) 30
3 Sanitary Worker 20
4 Ophthalmic Assistant / Refractionist 2
5 Social Worker / Counsellor 2
6 Cytotechnician 1
7 ECG Technician 1
8 ECHO Technician 1
9 Audiometrician 1
10 Laboratory Technician ( Lab + Blood Bank) 12
11 Laboratory Attendant (Hospital Worker) 4
12 Dietician 1
13 PFT Technician 1
14 Maternity assistant (ANM) 4

17
15 Radiographer 3
16 Dark Room Assistant 2
17
Pharmacist1 8
18 Matron 7
19 Physiotherapist 2
20 Statistical Assistant 1
21 Medical Records Officer / Technician 2
22 Electrician 1
23 Plumber 1
Total 207
*
1 Staff Nurse for every eight beds with 25% reserve
1
Two may be from AYUSH

C. Administrative Staff
Current
Remarks /
Availability at
Suggestions /
S.No. Personnel IPHS Norm Hospital
Identified
(Indicate
Gaps
Numbers)
1 Manager (Administration) 1
2 Junior Administrative Officer 1
3 Office Superintendent 2
4 Assistant 5
5 Junior Assistant / Typist 3
6 Accountant 2
7 Record Clerk 3
8 Office Assistant 2
9 Computer Operator 2
10 Driver 3
11 Peon 2
12 Security Staff* 2
13 Total 28
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
(Indicate

Remarks / Suggestions /
Current Availability at

Identified Gaps
Numbers)

S.No. Staff IPHS Norm


Hospital

Emergency / FW
OPTH. / ENT A&E Elective
OT

1 Staff Nurse 5 2 1 3
2 OT Assistant 4 2 2 2

18
3 Sweeper 2 1 1 1
Total 11 5 4 6

E. Blood Bank / Blood Storage

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

19
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.
Bacteriological analysis of water by Rapid H2S
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
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

20
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 tests
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

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)

21
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

22
Medico-
legal/post
Ambulan
mortem
ce
services
Dietary
services
Laundry
services
Security
services
Electric
Counseling services for domestic violence, gender violence, adolescents, etc. Gender and socially sens
Waste
Ware
Supply
managem
housing/c
(power
ent
entral
Maintena
generatio
store
nnce
Water and
Heating,
repair
stabilizati
supply
ventilatio
on)
(plumbin
n and air-
g)
condition
ing
Transport
Communi
Medical
cation
Social
Sterilizati
Work
Nursing
on and
Horticult
Services
Disinfecti
ure
on
(Landsca
Lift and
ping)
vertical
transport
Refrigera
tion
Gender and socially sensitive service delivery be assured.

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