Plan of field visits for monitoring

FACILITY
LEVEL

MONITORING
OFFICER

MINIMUM LEVEL OF OBSERVATION

HSC

LHV

Atleast 3 days / week, to one SC per visit

Every SC will be covered twice a month
At least 1 VHND / Week

Medical Officer-PHC

Block MO-i/c

Block Programme
Manager

Public Health Nurse

CMO

District Programme
Manager

Atleast twice a month to 2 weak performing SCs /

ANMs and 2 VHNDs / Month
At least twice a month to 2 weak performing PHCs and
2 weak performing SCs
At least twice a week ie. 8 times in a month
2 SCs / Outreach and household assessment
per visit OR
1 PHC and 1 SC/outreach and household
assessment per visit
At least twice a week ie. 8 times in a month
1 PHC and 1 SC per visit OR
2 SCs, 1 outreach and household assessment
per visit
At least twice a month to any weak performing facility
and outreach
At least once a week ie. 4 times in a month
1 CHC and 1 SC per visit OR
2 PHCs and 1 SC per visit OR
1 PHC, 1 SC, 1 outreach and household

RCHO/ADHO/ACMO
and other technical
officers

At

Divisional

Regional Programme
Manager / Divisional
Programme Manager

At least once a week ie. 4 times in a month to different

districts by rotation
2 CHC-FRUs / SDH per visit OR
1 CHC-FRU/SDH and 1 PHC per visit OR
1 PHC, 2 SCs / outreach and household

State

Mission Director

At least twice a month to one poor performing district

per visit, Ideally 1 SC, 1 PHC and 1 CHC / DH to be
visited per visit

State Programme
Manager

Senior Officer of
State Directorate /
State Technical
Programme Officer

At least twice a month to one poor performing district

per visit. Ideally 1 SC, 1 PHC and 1 CHC/DH to be
visited per visit
At least twice a month to one poor performing district
per visit. Ideally 1 SC, 1 PHC and 1 CHC/DH to be
visited per visit

CHC

District

least once a eweek ie. 4 times in a month

1 CHC and 1 SC per visit OR
2 PHCs and 1 SC per visit OR
1 PHC, 1 SC, 1 outreach and household

Based on the observations during field visits, plan of action to be made.

Action Points with timelines and officials responsible for action points to be
uploaded on the State NRHM Website

Sub Centre level Monitoring Checklist

Name of the District:______________

Name of Block: _____________

Name of SC: __________

Catchment Population: _________

Total Villages: ______________

distance from PHC: ___

Date of last supervisory visit: _____

Date of visit: ____________

Name & designation of monitor: _____________________

Names of staf posted and available on the day of visit: _____________________________________

Name of staff not available on the day of visit and reason for absence: ______________________

Section I: Physical Infrastructure:

S.No.
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10

Infrastructure
Subcentre located near a main
habitation
Functioning in Govt. building
Building in good condition
Electricity with functional power
back up
Running 24*7 water supply
ANM quarter available
ANM residing at SC
Functional labour room
Functional and clean toilet
accached to labour room
Functional New Born Care Corner
(Functional radiant warmer with neo-natal

Yes
Y

No
N

Y
Y
Y

N
N
N

Y
Y
Y
Y
Y

N
N
N
N
N

Y
Y

N
N

Remarks

ambu bag)

1.11
1.12
1.13

General cleanliness in the facility

Availability of complain /
suggestion box
Availability of deep burial pit for
waste management / any other
mechanism

Section II: Human Resource:

S.No.
2.1
2.2
2.3

Human Resource
ANM
2nd ANM
MPW Male

Numbers

Specify the
Training
received

Remarks

2.4

Others, specify

Section III: Equipment

Mark ( ) in appropriate column

S.
No.
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10

Equipment

Available
and
functional

Available
but not
functional

Not
available

Remarks

Equipment for Hemoglobin

Estimation
Blood sugar testing kits
BP Instrument and
Stethoscope
Delivery equipment
Neonatal ambu bag
Adult weighing machine
Infant / New born weighing
machine
Needle & Hub Cutter
Color coded bins
RBSK pictorial tool kit

Section IV: Essential Drugs

S.No.
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10

Availability of at least 2 month

stock of essential Drugs
IFA tablets
IFA syrup with dispenser
Vit A syrup
ORS packets
Zinc tablets
Inj Magnesium Sulphate
Inj Oxytocin
Misoprostol tablets
Antibiotics, if any, pls specify
Availability of drugs for common
ailments e.g PCM, anti-allergic
drugs etc.

Yes

No

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N

Yes
Y
Y

No
N
N

Y
Y
Y

N
N
N

Remarks

Section V: Essential Supplies

S.No.
5.1
5.2
5.3
5.4
5.5

Essemtial Medical Supplies

Pregnancy testing Kits
Urine albumin and sugar testing
kit
OCPs
EC pills
IUCDs

Remarks

5.6

Sanitary napkins

Section VI: Service Delivery in the last two quarters

S.No.
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
6.13 a
6.15
6.16
6.17
6.18
6.19
6.20
6.21
6.22
6.23

Availability of at least 2 month

stock of essential Drugs
Number of estimated
pregnancies
Percentage of women registered
in the first trimester
Percentage of ANC3 out of total
registered
Percentage of ANC4 out of total
registered
No. of pregnant women given IFA
Number of deliveries conducted
at SC
Number of deliveries conducted
at home
No. of neonates initiated breast
feeding within one hour
Number of children screened for
defects at birth under RBSK
No. of sick children referred
No. of pregnant women referred
No. of IUCD insertions
No. of children fully immunized
Measles coverage
No. of children given ORS + Zinc
No. of children given Vitamin A
No. of children given IFA Syrup
No. of Maternal deaths recorded
if any
No. of still birth recorded, if any
Neonatal deaths recorded, if any
Number of VHNDs attended
Number of VHNSC meeting
attended
Service delivery data submitted
for MCTS updation

Q1

Q2

Remarks

Section VII: Physical Infrastructure:

S.No.
7.1
7.2
7.3
7.4

Essential Skill Set

Correctly measure BP
Correctly measure
hemoglobin
Correctly measure urine
albumin and protein
Identify high risk

Knowledge
Y
N
Y
N

Skill

Remarks

Y
Y

N
N

7.5
7.6

pregnancy
Awareness on mechanisms
for referral to PHC and FRU
Correct use of partograph

7.7

Provide essential newborn

care (thermoregulation,

Y
Y

N
N

Y
Y

N
N

breastfeeding and asepsis)

7.8
7.9
7.10
7.11
7.12
7.13

7.14
7.15

Correctly insert IUCD

Correctly administer
vaccine
Adherence to IMEP
protocols
Segregation of waster in
colour coded bins
Guidance / Support for
breast feeding method
Correctly identified signs of
Pneumonia and
dehydration
Awareness on
Immunization Schedule
Awareness on site of
administration of vaccine

Section VIII: Record Maintenance

Mark ( ) in appropriate column

S.
No.

8.1

Record

Untied funds expenditure

(Rs.10,000) Check %
expenditure

8.2

Annual maintenance grant

(Rs.10,000) Check %
expenditure

8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11
8.12

Payments under JSY

VHND plan
VHSNC meeting minutes
and action taken
Eligible couple register
MCH register (as per GOI)
Delivery Register as fper
GOI format
Stock register
Due lists
MCP cards
Village register

Available
and
uptodate
and
correctly
filled

Available
but nonmaintained

Not
available

Remarks

8.13
8.14
8.15

Referral Registers (in and

out)
List of families with 0-6
years children under RBSK
Line listing of severely
anemic pregnant women

8.16
8.17

8.18

Updated Microplan
Vaccine supply for each
session day (check
availability of all vaccines)
Due list and work lan
received from MCTS Portal
through Mobile / Physically

Section IX: Referral Linkages in last two quarters

Mode of
Transport
(Specify
Govt./ pvt)

S.
No.

No. of women
transported
during
ANC/INC/PNC

No. of sick
infants
transported

No. of
children
1-6 years

9.1 Home to
facility
9.2 Inter facility
9.3 Facility to
Home (drop
back)

Section X: IEC display

S.No.

Material

Yes

No

10.1

10.2

Approach roads have directions to

the sub centre
Citizen Charter

10.3

Timings of the Sub Centre

10.4

Visit schedule of ANMs

10.5

10.6

Area distribution of the ANMs /

VHND plan
SBA Protocol Posters

10.7

JSSK entitlements

10.8

Immunization Schedule

10.9

JSY entitlements

10.10 Other related IEC material

Remarks

Free/Paid

Section IV: Essential Drugs

S.No.

Name and Designation of the

supervisor

Place of posting of
Supervisor

Date of visit

11.1
11.2
11.3
11.4
11.5

Note: Ensure that necessary corrective measures are highlighted and if possible, action taken on the spot,.
The monthly report of monitoring visits and action points must be submitted to the appropriate authority for
uploading an State MoHFW website

To be filled by monitor(s) at the end of activity

Section IV: Essential Drugs

Key Findings

Action Taken / Proposed

Person(s)
responsible

Time line

Household Visit (Families with 0 6 years children)

Indicators
1. Breast
Feeding

Knowledge and Awareness

Households

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

Total

Is the mother aware that Breast feeding (BF) must be initiated

within one hour after birth?
Did the mother initiate BF within one hour of birth?

2. Complementary
Feeding
Practices

Is the mother aware that Exclusive Breast feeding should be

done for six months and continued till chindl attains age of 2
years?
Has the mother Exclusively Breast fed her youngest child for
six months and continued BF till 2 years?
Is she aware about initiating Complementary Feeding (CF)
from 6 months onwards?
Has she adhered to initiating CF from 6 months onwards?

3. Diarrhoea

Does the mother know that ORS+Zinc available with ASHAs?

As per mother, is ORS+Zinc available with ASHAs?

4. Pneumonia

Can mother tell at least two danger signs of pneumonia?

Is she aware whom to approach on recognizing the danger
signs?

Household Visit (Pregnant Woman / High Risk Pregnant Women)

Key Questions

Households

Is the MCP card being regularly filled?*

Is the quality of ANC and regularity of ANCs adequate?*
Is the pregnant woman aware about birth preparedness?
Does the pregnant woman have knowledge of JSY and JSSK?
Whether the pregnant woman has received safe motherhood booklet?
Does the pregnant woman have the telephone number of call center for referral
transport / other available referral transport?

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

Total

Does the pregnant woman have telephone numbers of ASHA / ANM?

Is guidance and referral provided along with birth preparedness in case of high risk
pregnant woman?
* (Probe by questions and verify through filled up MCP card)

PHC/CHC(NON FRU) level Monitoring Checklist

Name of the District:___________

Name of Block: ________

Name of PHC/CHC: ______

Catchment Population: _________

Total Villages: _________

distance from PHC: ___

Date of last supervisory visit: ___________

Date of visit: ____________

Name & designation of monitor: _____________________

Name of staff not available on the day of visit and reason for absence: ______________________

Section I: Physical Infrastructure:

S.No.
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12

1.13
1.14
1.15
1.16
1.17

Infrastructure
Health facility easily accessible from
nearest road head
Functioning in Govt. building
Building in good condition
Habitable Staff Quarters for MOs
Habitable Staff Quarters for SNs
Habitable Staff Quarters for other
categories
Electricity with functional power
back up
Running 24*7 water supply
Clean Toilets separate for Male /
Female
Functional and labour room
Functional and clean toilet
accached to labour room
Functional New Born Care Corner
(Functional radiant warmer with
neo-natal ambu bag)
Functional Newborn Stabilization
Unit
Clean wards
Separate Male and Female wards (at
least by partitions)
Availability of complain / suggestion
box
Availability of mechanisms for waste
management

Yes
Y

No
N

Y
Y
Y
Y
Y

N
N
N
N
N

Y
Y

N
N

Y
Y

N
N

Y
Y

N
N

Remarks

Section II: Human Resource:

S.No.

Category

Numbers

Remarks if any

2.1
2.2
2.3
2.4
2.5

Mo
SNs / GNMs
ANM
L.Ts
Pharmacist

2.6
2.7

LHV/PHN
Others

Section III: Training Status of HR

S.No.
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12

Training
BeMOC
SBA
MTP/MVA
NSV
IMNCI
F-IMNCI
NSSK
Mini Lap
IUD
RTI / STI
Immunization and cold chain
Others

No. trained

Remarks if any

Section IV: Equipment

S.No.
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
4.15
4.16
4.17
4.18

Equipment
Functional BP Instrument and
Stethoscope
Sterilised delivery sets
Functional neonatal, Paediatric
and Adult Resuscitation kit
Functional Weighing Machine
(Adult and Infant / newborn)
Functional Needle Cutter
Functional Radiant Warmer
Functional Suction Apparatus
Functional Facility for Oxygen
Administration
Functional Autoclave
Functional ILR
Functional Deep Freezer
Emergency Tray with emergency
injections
MVA / EVA Equipment
Laboratory Eqipment
Functional Microscope
Functional Hemoglobinometer
Functional Centrifuge
Functional Semi Autoanalyzer
Reagents and Testing Kits

Yes
Y

No
N

Y
Y

N
N

Y
Y
Y
Y

N
N
N
N

Y
Y
Y
Y

N
N
N
N

Y
Yes

N
No

Y
Y
Y
Y
Y

N
N
N
N
N

Remarks

Remarks

Section V: Essential Drugs and Supplies

S.No.
5.1
5.2

5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15

5.16
S.No.
5.17
5.18
5.19
5.20
5.21
5.22
S.No.
5.23

Drugs
EDL available and displayed
Computerised inventory
management
IFA tablets
IFA tablets (blue)
IFA syrup with dispenser
Vit A syrup
ORS packets
Zinc tablets
Inj Magnesium Sulphate
Inj Oxytocin
Misoprostol tablets
Mifepristone tablets
Antibiotics
Labelled emergency tray
Drugs for hypertension, Diabetes,
common ailments e.g PCM, antiallergic drugs etc.
Vaccine stock avialable

Yes
Y
Y

No
N
N

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N
N
N
N

Supplies
Pregnancy testing kits
Urine albumin and sugar te

Yes
Y
Y
Y
Y
Y
Y
Yes
Y

No
N
N
N
N
N
N
No
N

Essential Consumables
Gloves, Mackintosh, Pads,
bandages, and gauze etc.

Remarks

Ramarks

Ramarks

Note: For all drugs and consumables, availability of at least 2 month stock to be
observed and noted

Section VI: Other Services

S.No.
6.1
6.2
6.3
6.4
6.5
6.6
6.7

Lab tests being conducted for

Haemoglobin
CBC
Urine albumin and Sugar
Serum Bilirubin test
Blood Sugar
RPR (Rapid Plasma Reagin) test
Malaria (PS or RDT)

Yes
Y
Y
Y
Y
Y
Y
Y

No
N
N
N
N
N
N
N

Remarks

6.8
6.9
6.10

T.B (Sputum for AFB)

HIV (RTD)
Others

Y
Y
Y

N
N
N

Section VI: Service Delivery in the last two quarters

S.No.
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8

7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16
7.17
7.18
7.19
7.20
7.21
7.22
7.23
7.24
7.25
7.26
7.27
7.28

Availability of at least 2 month

stock of essential Drugs
OPD
IPD
Expected Number of pregnancies
Percentage of women registered
in the first trimester
Percentage of ANC3 out of total
registered
Percentage of ANC4 out of total
registered
Total deliveries conducted
Number of obstetric
complications managed, pls
specify type
No. of neonates initiated breast
feeding within one hour
Number of children screened for
defects at birth under RBSK
RTI/STI Treated
No. of admissions in NBSUs, if
available
No. of sick children referred
No. of pregnant women referred
No. of IUCD insertions
No. of Tubectomy
No. of Vasectomy
No. of Minilap
No. of children fully immunized
Measles coverage
No. of children given ORS + Zinc
No. of children given Vitamin A
No. of women who accepted post
partum FP services
No. of MTPs conducted
Maternal deaths, if any
Still births, if any
Neonatal deaths, if any
Infant deaths, if any

Q1

Q2

Remarks

Section VII: Service delivery in post natal wards

S.No.
7.1a
7.2a
7.3a
7.4a
7.5a
7.6a
7.7a

7.8a

7.9a

Parameters
All mothers initiated breast feeding
within one hour of normal delivery
Zero dose BCG, Hepatitis B and
OPV given
Counselling on IYCF done
Counselling on Family Planning
done
Mothers asked to stay for 48 hrs
JSY payment being given before
discharge
Mode of JSY payment (Cash /
bearer cheque / Acount payee
cheque / Account Transfer)
Any expenditure incurred by
Mothers on travel, drugs or
diagnostics (Please give details)
Diet being provided free of charge

Yes
Y

No
N

Y
Y

N
N

Y
Y

N
N

Remarks

Section VIII: Quality parameter of the facility

(Through probing questions and demonstrations assess does the staff nurses and ANMs know how to.

S.No.
8.1
8.2

8.3
8.4
8.5
8.6
8.7
8.8
8.9

Essential Skill Set

Manage high risk
pregnancy
Provide essential newborn
care (thermoregulation,
breastfeeding and asepsis)
Manage sick neonates and
infants
Correctly uses partograph
Correctly insert IUCD
Correctly administer
vaccines
Alternate Vaccine Delivery
(AVD) system functional
Segregate waste in colour
coded bins
Adherence to IMEP
protocols

Knowledge
Y
N

Skill

Remarks

Y
Y
Y

N
N
N

Y
Y
Y

N
N
N

Section IXI: Record Maintenance

S.
No.

Available
updated
and
correctly
filled

Record

9.1

OPD Register

9.2

IPD Register

9.3

ANC Register

9.4

PNC Register

9.5

Indoor bed head ticket

9.6

Line listing of severely

anaemic pregnant women

9.7

Labour room register

9.8

Partographs

9.9

OT Register

9.10

FP Register

9.11

Immunisation Register

9.12

Updated Microplan

9.13

Drug Stock Register

9.14

Referral Registers (In and Out)

9.15

Payments under JSY

9.16

Untied funds expenditure

(Check % expenditure)

9.17

AMG expenditure (Check %

expenditure)

9.18

RKS expenditure (Check %

expenditure)

Available
but nonmaintained

Not
available

Remarks /
Timeline for
completion

Section X: Referral linkages in last two quarters

S.
No.

JSSK

10.1

Home to facility

10.2

Inter facility

10.3

Facilty to Home (drop

back)

Mode of
Transport
(Specify
Govt /
Pvt)

No. of
women
transporte
d during
ANC /
INC / PNC

No. of sick
infants
transporte
d

No. of
children
1-6
years

Free /
Paid

Section XI: IEC Display

S.No.
11.1
11.2
11.3
11.4
11.5
11.6
11.7
11.8
11.9
11.10

Material
Approach roads have directions to
the health facility
Citizen Charter
Timings of the Health Facility
List of services available
Essential Drug List
Protocol Posters
JSSK entitlements
Immunization Schedule
JSY entitlements
Other related IEC material

Yes
Y

No
N

Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N

Remarks

Section XII: Additional / Support Services

S.No.
12.1
12.2
12.3
12.4
12.5
12.6
12.7

Material
Regular sterilisation of Labour room
(Check Records)
Functional laundry / washing
services
Availability of dietary services
Appropriate drug storage facilities
Equipment maintenance and repair
mechanism
Grievance redressal mechanisms
Tally software implemented

Yes
Y

No
N

Y
Y
Y

N
N
N

Y
Y

N
N

Remarks

Section XIII: Previou Supervisory Visits

S.No.

Name and Designation of the

Supervisor

Place of
posting of
Supervisor

Date of visit

13.1
13.2
13.3
13.4
13.5
Note: Ensure that necessary corrective measures are highlighted and if possible, action taken on the
spot. The Monthly report of monitoring visits and action points must be submitted to the appropriate
authority for uploading on State MoHFW website
____________________________________________________

To be filled by monitor(s) at the end of activity

Key Findings

Action Taken / Proposed

Person(s)
Responsible

Timeline