Annexure III - PMSMA€¦ · Inj Tetanus toxoid D14 Tab Paracetamol D3 Cap Ampicillin D9 Tab....
11
24 Pradhan Mantri Surakshit Matritva Abhiyan Annexure III 3.1: Pradhan Mantri Surakshit Matritva Abhiyan Onsite Monitoring Format State: …………………......... District: …………………......... Block: …………………......... Urban/Rural: …………………........................... Date: …./…....../…... Time of visit: .....: ..... Name of health facility: ……………...... Type of facility: DH/SDH/CHC/PHC/Private Name of monitor: ………………….......................Designation: ………………….....................Organization: ………………….................. Availability of HR/ Equipments/ Drugs/ Diagnostics Secon – A: Service Provider Informaon: Sr. No. Category Available (Yes/No) No. (s) Sr. No. Category Available (Yes/No) No. (s) A1 Obs & Gynae Specialist A4 Staff Nurses (SN) A2 Medical Officer (MO) A.4.1 Staff Nurses (Trained in SBA/ Dakshata) A2.1 CEmOc trained A5 Auxiliary Nurse Midwife (ANM) A2.2 BEmOC trained A.5.1 ANM (Trained in SBA/ Dakshata) A3 Private provider (O & G/ MO ) A6 Counsellor (RMNCH+A/SN/ANM)
Transcript of Annexure III - PMSMA€¦ · Inj Tetanus toxoid D14 Tab Paracetamol D3 Cap Ampicillin D9 Tab....
24 Pradhan Mantri Surakshit Matritva Abhiyan
Ann
exur
e III
3.1:
Pra
dhan
Man
tri S
urak
shit
Mat
ritv
a A
bhiy
an O
nsit
e M
onit
orin
g Fo
rmat
Stat
e: …
……
……
……
......
...
Dist
rict:
……
……
……
…...
......
Blo
ck: …
……
……
……
......
... U
rban
/Rur
al: …
……
……
……
......
......
......
......
...
Date
: …./
…...
.../…
... T
ime
of v
isit:
.....:
.....
Nam
e of
hea
lth fa
cilit
y: …
……
……
......
Typ
e of
faci
lity:
DH/
SDH/
CHC/
PHC/
Priv
ate
Nam
e of
mon
itor:
……
……
……
…...
......
......
......
..Des
igna
tion:
……
……
……
…...
......
......
......
Org
aniza
tion:
……
……
……
…...
......
......
...
Ava
ilabi
lity
of H
R/ E
quip
men
ts/
Dru
gs/
Dia
gnos
tics
Secti
on –
A: S
ervi
ce P
rovi
der
Info
rmati
on:
Sr.
No.
Cate
gory
Ava
ilabl
e (Y
es/N
o)N
o.
(s)
Sr.
No.
Cate
gory
Ava
ilabl
e(Y
es/N
o)N
o.
(s)
A1O
bs &
Gyn
ae S
peci
alist
A4St
aff N
urse
s (SN
)
A2M
edic
al O
ffice
r (M
O)
A.4.
1St
aff N
urse
s (Tr
aine
d in
SBA
/ Dak
shat
a)
A2.1
CEm
Oc
trai
ned
A5Au
xilia
ry N
urse
Mid
wife
(AN
M)
A2.2
BEm
OC
trai
ned
A.5.
1AN
M (T
rain
ed in
SBA
/ Dak
shat
a)
A3Pr
ivat
e pr
ovid
er
(O &
G/ M
O )
A6Co
unse
llor (
RMN
CH+A
/SN
/AN
M)
25Operational Framework
Secti
on –
B: E
ssen
tial
Equ
ipm
ent (
Veri
fy p
hysi
cally
for
avai
labi
lity
and
func
tion
alit
y)
S.
No.
Equi
pmen
t’s
& In
stru
-m
ents
Yes/
N
oN
o.Eq
uipm
ent’
s &
Inst
rum
ents
Yes/
N
oS.
N
o.Eq
uipm
ent’
s &
In-
stru
men
tsYe
s/
No
B1BP
App
arat
usB2
Adul
t ste
thos
cope
B3W
eigh
ing
mac
hine
B4He
ight
scal
eB5
Mea
surin
g ta
peB6
Torc
h
B7Th
erm
omet
erB8
Feto
scop
e/Do
pple
r for
FHS
B9St
erile
Glo
ves
Secti
on –
C: D
iagn
osti
c Se
rvic
es
(Con
firm
the
avai
labi
lity
of la
b te
sts
for
follo
win
g: W
rite
yes
for
each
labo
rato
ry s
ervi
ce a
vaila
ble
in h
ouse
.)
S. N
o.D
iagn
osti
c Se
rvic
esYe
s/ N
oN
o.D
iagn
osti
c Se
rvic
esYe
s/ N
o
C1He
mog
lobi
nC5
Poin
t of C
are
Test
for S
yphi
lis/ V
DRL/
RPR
C2U
rine
Albu
min
& S
ugar
C6W
hole
Blo
od F
inge
r Pric
k Te
st
C3Sc
reen
ing
for G
esta
tiona
l Di
abet
es M
ellit
us (O
GTT)
C7Bl
ood
Grou
ping
C4M
alar
ia th
roug
h RD
K
(in e
ndem
ic a
reas
)C8
Ultr
asou
nd In
-hou
se O
utso
urce
d
26 Pradhan Mantri Surakshit Matritva Abhiyan
Secti
on –
D: D
rugs
Ava
ilabl
e
(che
ck th
e av
aila
bilit
y of
eac
h dr
ug a
t the
PM
SMA
Clin
ic o
r ph
arm
acy.
Wri
te y
es/n
o ac
cord
ingl
y. If
ade
quat
e st
ock
not a
vaila
ble
men
tion
in y
our
rem
arks
)
S.
No.
Equi
pmen
t’s
& In
stru
-m
ents
Yes/
N
oN
o.Eq
uipm
ent’
s &
Inst
rum
ents
Yes/
N
oS.
N
o.Eq
uipm
ent’
s &
In-
stru
men
tsYe
s/
No
D1IF
A Ta
blet
sD7
Inj.
Dexa
met
haso
neD1
3Ta
b. L
abet
alol
D2Ta
b Fo
lic A
cid
D8In
j Tet
anus
toxo
idD1
4Ta
b Pa
race
tam
ol
D3Ca
p Am
pici
llin
D9Ta
b. C
alci
um 5
00 m
g &
Vit
D3D1
5Ta
b Ch
loro
quin
e
D4Ca
p Am
oxic
illin
D10
Tab.
Alb
enda
zole
D16
Tab
Nife
dipi
ne
D5Ta
b M
etro
nida
zole
D11
Tab.
Met
hyld
opa
D17
Eryt
hrom
ycin
D6Ge
ntam
icin
D12
Inj.
Labe
talo
l D1
8Ta
b Pa
race
tam
ol
27Operational Framework
Secti
on E
: Inf
rast
ruct
ure
(Con
firm
the
avai
labi
lity
of fo
llow
ing
basi
c in
fras
truc
ture
)
Sr. N
o.In
fras
truc
ture
Yes/
No
E1Cl
ean
Toile
t for
PW
E2Ad
equa
te w
aitin
g sp
ace
for w
omen
E3Pr
ovisi
on o
f drin
king
wat
er
E4Ex
amin
ation
tabl
es in
AN
C cl
inic
E5Ad
equa
te S
ign
posti
ng fo
r AN
C se
rvic
es
E6IE
C M
ater
ial o
n PM
SMA
28 Pradhan Mantri Surakshit Matritva Abhiyan
Serv
ice
Del
iver
y (C
heck
if w
omen
are
rec
eivi
ng th
e fo
llow
ing
serv
ices
)
Secti
on F
: Ide
ntific
ation
and
Man
agem
ent
of H
igh
Risk
Pre
gnan
cies
Sr. N
o.In
fras
truc
ture
Yes/
No
Yes/
No
F1W
omen
iden
tified
with
ana
emia
F5W
omen
iden
tified
as S
erop
ositi
ve fo
r HI
V
F2Ad
equa
te w
aitin
g sp
ace
for
wom
enF6
Wom
en id
entifi
ed S
erop
ositi
ve fo
r syp
hilis
F3Pr
ovisi
on o
f drin
king
wat
erF7
Wom
en id
entifi
ed w
ith h
ypot
hyro
idism
F4Ex
amin
ation
tabl
es in
AN
C cl
inic
F9W
omen
iden
tified
with
any
oth
er h
igh
risk
fact
or
F10
IFA
dist
ributi
onF1
3Tr
eatm
ent f
or D
iabe
tes
F11
Calc
ium
supp
lem
enta
tion
F14
Trea
tmen
t for
oth
er h
igh
risk
fact
ors
F12
Trea
tmen
t for
Hyp
erte
nsio
nF1
5P.W
with
hig
h ris
k fa
ctor
s ref
erre
d fo
r fur
ther
tr
eatm
ent
29Operational Framework
Secti
on G
: Cou
nsel
ling
Serv
ices
G1
Coun
selli
ng S
ervi
ces
bein
g pr
ovid
ed (Y
/N)
G2Ca
dre
Prov
idin
g Co
unse
lling
(Ple
ase
spec
ify if
RM
NCH
+A c
ouns
ello
r/SN
/AN
M p
rovi
ding
cou
nsel
ling)
G3Is
Gro
up C
ouns
ellin
g be
ing
done
(Y/N
)
G4Is
One
on
One
Cou
nsel
ling
bein
g do
ne (Y
/N)
G5Is
a C
ouns
ellin
g to
ol a
vaila
ble
(Y/N
) eg
flipb
ook/
safe
mot
herh
ood
book
let
G6Ar
e w
omen
cou
nsel
led
for B
irth
Prep
ared
ness
and
Com
plic
ation
Rea
dine
ss
G7Ar
e w
omen
cou
nsel
led
for p
ost-p
artu
m fa
mily
pla
nnin
g
G8Ar
e w
omen
cou
nsel
led
on N
utriti
on d
urin
g pr
egna
ncy
30 Pradhan Mantri Surakshit Matritva Abhiyan
Doc
umen
tati
on:
(Ple
ase
veri
fy p
hysi
cally
if t
he fo
llow
ing
reco
rds
are
avai
labl
e an
d be
ing
mai
ntai
ned)
Sr. N
o.Re
cord
Yes/
No
H1
AN
C Re
gist
er
H2Li
ne li
st o
f HRP
H3M
CP C
ards
H4PM
SMA
repo
rting
For
mat
s
Secti
on I:
Che
ck M
CP C
ards
of 5
wom
en w
ho h
ave
com
plet
ed t
heir
AN
C du
ring
the
PM
SMA
W
rite
Yes
, if t
he p
aram
eter
has
bee
n re
cord
ed
Ges
tati
onal
Age
Hem
oglo
bin
Wei
ght
BPFH
SA
bdom
inal
Exa
min
ation
USG
A
ppro
pria
te C
olor
sti
cker
Case
1
Case
2
Case
3
Case
4
Case
5
31Operational Framework
3.2:
Dis
tric
t Ass
essm
ent C
heck
list P
radh
an M
antr
i Sur
aksh
it M
atri
tva
Abh
iyan
Stat
e: ..
......
......
......
......
......
......
......
......
.. D
istr
ict:
.....
......
......
......
......
......
......
.Nam
e of
mon
itor
: ....
......
......
......
......
...
Org
aniz
ation
: ....
......
......
......
......
......
......
......
......
......
.. D
ate/
s of
vis
it: .
......
......
......
......
......
......
......
......
......
......
......
...
Mon
itor
s sh
ould
mee
t Pro
gram
me
Offi
cer
– PM
SMA
and
oth
er d
istr
ict-
leve
l offi
cers
for
advo
cacy
of P
MSM
A a
nd
also
to d
ebri
ef th
em a
bout
thei
r ob
serv
ation
s w
ith
sugg
este
d co
rrec
tive
acti
ons.
1.Is
the
initi
ative
bei
ng im
plem
ente
d in
all
bloc
ks?
If no
t, pr
ovid
e de
tails
(if
impl
emen
ted
in a
ll di
stric
ts ju
st w
rite
all).
Also
pro
vide
num
ber o
f fac
ilitie
s in
urba
n ar
eas c
orpo
ratio
ns w
here
PM
SMA
is be
ing
impl
emen
ted
......
......
... o
ut o
f ....
......
..blo
cks
......
......
......
......
......
.num
ber o
f fac
ilitie
s in
urb
an a
reas
2.St
atus
of Q
uart
erly
Dist
rict l
evel
PM
SMA
Mee
ting:
h
eld
n
ot h
eld
If h
eld,
min
utes
ava
ilabl
e?
Yes
N
o
3.a
Have
the
dist
rict o
ffici
als a
ttend
ed a
ny S
tate
leve
l orie
ntati
on?
Y
es
No
If ye
s, w
hen
was
it h
eld?
.....
......
......
......
....
3.b
Has t
he d
istric
t org
anize
d an
orie
ntati
on o
f blo
ck le
vel o
ffici
als?
Y
es
No
If ye
s, w
hen
was
it h
eld?
.....
......
......
......
..
4.N
umbe
r of h
ealth
faci
lities
whe
re c
urre
nt ro
und
of P
MSM
A is
plan
ned
to b
e co
nduc
ted
inAv
erag
e of
Cu
rren
t Qua
rter
Aver
age
of
Prev
ious
Qua
rter
4.a
Med
ical
Col
lege
s
4.b
DH
4.c
SDH
4.d
CHC/
UCH
C/ m
ater
nity
hom
es
4.e
PHC/
UPH
C
4.f
Oth
er fa
ciliti
es su
ch a
s rai
lway
hos
pita
ls et
c (n
ot fu
nded
by
NHM
but
vol
unta
rily
cond
uctin
g PM
SMA)
32 Pradhan Mantri Surakshit Matritva Abhiyan
Stat
e: ..
......
......
......
......
......
......
......
......
.. D
istr
ict:
.....
......
......
......
......
......
......
.Nam
e of
mon
itor
: ....
......
......
......
......
...
Org
aniz
ation
: ....
......
......
......
......
......
......
......
......
......
.. D
ate/
s of
vis
it: .
......
......
......
......
......
......
......
......
......
......
......
...
Mon
itor
s sh
ould
mee
t Pro
gram
me
Offi
cer
– PM
SMA
and
oth
er d
istr
ict-
leve
l offi
cers
for
advo
cacy
of P
MSM
A a
nd
also
to d
ebri
ef th
em a
bout
thei
r ob
serv
ation
s w
ith
sugg
este
d co
rrec
tive
acti
ons.
5.
Has t
he D
istric
t pla
nned
to in
volv
e Pr
ivat
e Se
ctor
in th
e PM
SMA?
Y
es
No
If ye
s, n
umbe
r of p
rivat
e pr
ovid
ers t
hat h
ave
been
invo
lved
in P
MSM
A ...
......
......
......
......
......
......
......
......
......
......
......
......
...
Have
IMA/
FO
GSI/
Rot
ary/
Lio
ns C
lub
etc
been
invo
lved
in P
MSM
A. If
yes
, pro
vide
det
ails.
......
......
......
......
......
......
......
.....
(atta
ch c
omm
ents
in se
para
te sh
eet i
f req
uire
d)
6.Ha
s the
dist
rict o
rgan
ized
a la
unch
of P
MSM
A? Y
es
No
7.If
yes,
who
laun
ched
the
PMSM
A?
8.Ho
w m
any
stat
e le
vel o
ffice
rs h
ave
been
sent
as s
tate
obs
erve
rs to
dist
ricts
in
the
curr
ent r
ound
/ pre
viou
s qua
rter
(Spe
cify
)
9.Ha
ve th
e m
onth
ly re
porti
ng fo
rmat
for P
MSM
A be
en c
omm
unic
ated
to
bloc
ks?
Yes
N
o
10.
Has t
he d
istric
t pre
pare
d an
IEC
plan
for P
MSM
A?
If ye
s, k
indl
y pr
ovid
e de
tails
Yes
N
o...
......
......
......
......
......
......
......
11.
Have
RM
NCH
+A p
artn
ers b
een
invo
lved
in th
e im
plem
enta
tion
of P
MSM
A?If
yes,
kin
dly
prov
ide
deta
ils Y
es
No
12.
Rem
arks
/Com
men
ts (4
-5 p
oint
s, w
hich
, acc
ordi
ng to
you
can
pla
y a
sign
ifica
nt ro
le in
impr
ovin
g th
e im
plem
enta
tion
of P
MSM
A in
the
dist
rict
. Als
o co
mm
ent i
f dis
tric
t ha
s in
trod
uced
any
inno
vati
ve s
trat
egy
for
impl
emen
ting
PM
SMA
.
33Operational Framework
3.3:
Sta
te A
sses
smen
t Che
cklis
t Pra
dhan
Man
tri S
urak
shit
Mat
ritv
a A
bhiy
an
Stat
e: ..
......
......
......
......
......
......
......
......
.. D
istr
ict:
.....
......
......
......
......
......
......
.Nam
e of
mon
itor
: ....
......
......
......
......
...
Org
aniz
ation
: ....
......
......
......
......
......
......
......
......
......
.. D
ate/
s of
vis
it: .
......
......
......
......
......
......
......
......
......
......
......
...
Mon
itor
s sh
ould
mee
t Pro
gram
me
Offi
cer
– PM
SMA
and
oth
er s
tate
-leve
l offi
cers
for
advo
cacy
of P
MSM
A a
nd a
lso
to d
ebri
ef th
em a
bout
thei
r ob
serv
ation
s w
ith
sugg
este
d co
rrec
tive
acti
ons.
1.N
umbe
r of D
istric
ts o
ut o
f tot
al d
istric
ts w
here
PM
SMA
is im
plem
ente
d (if
im
plem
ente
d in
all
dist
ricts
just
writ
e al
l)...
......
......
out
of .
......
.....
2.St
atus
of Q
uart
erly
Dist
rict l
evel
PM
SMA
Mee
ting:
h
eld
n
ot h
eld
If h
eld,
min
utes
ava
ilabl
e?
Yes
N
o
3.Ha
s a S
tate
leve
l orie
ntati
on o
f all
Dist
ricts
bee
n or
gani
zed?
Y
es
No
If ye
s, w
hen
was
it h
eld?
.....
......
......
......
......
..
4.N
umbe
r of h
ealth
faci
lities
whe
re c
urre
nt ro
und
of P
MSM
A ar
e co
nduc
ted
Aver
age
of
Curr
ent Q
uart
erAv
erag
e of
Pr
evio
us Q
uart
er
4.a
Med
ical
Col
lege
s
4.b
DH
4.c
SDH
4.d
CHC/
UCH
C/ m
ater
nity
hom
es
4.e
PHC/
UPH
C
4.f
Oth
er fa
ciliti
es (n
ot fu
nded
by
NHM
but
vol
unta
rily
cond
uctin
g PM
SMA)
34 Pradhan Mantri Surakshit Matritva Abhiyan
Stat
e: ..
......
......
......
......
......
......
......
......
.. D
istr
ict:
.....
......
......
......
......
......
......
.Nam
e of
mon
itor
: ....
......
......
......
......
...O
rgan
izati
on:
......
......
......
......
......
......
......
......
......
......
Dat
e/s
of v
isit
: ....
......
......
......
......
......
......
......
......
......
......
......
Mon
itor
s sh
ould
mee
t Pro
gram
me
Offi
cer
– PM
SMA
and
oth
er s
tate
-leve
l offi
cers
for
advo
cacy
of P
MSM
A a
nd a
lso
to d
ebri
ef
them
abo
ut th
eir
obse
rvati
ons
wit
h su
gges
ted
corr
ecti
ve a
ction
s.
5.
Has t
he D
istric
t pla
nned
to in
volv
e Pr
ivat
e Se
ctor
in th
e PM
SMA?
Y
es
No
If ye
s, n
umbe
r of p
rivat
e pr
ovid
ers t
hat h
ave
been
invo
lved
in P
MSM
A ...
......
......
......
......
......
......
......
......
......
......
......
......
...Ha
ve IM
A/ F
OGS
I/ R
otar
y/ L
ions
Clu
b et
c be
en in
volv
ed in
PM
SMA.
If y
es, p
rovi
de d
etai
ls....
......
......
......
......
......
......
......
...
(atta
ch c
omm
ents
in se
para
te sh
eet i
f req
uire
d)
6.Ha
s the
dist
rict o
rgan
ized
a la
unch
of P
MSM
A? Y
es
No
7.If
yes,
who
laun
ched
the
PMSM
A? C
hief
Min
ister
H
ealth
Min
ister
Oth
er (s
peci
fy)
8.Ho
w m
any
stat
e le
vel o
ffice
rs h
ave
been
sent
as s
tate
obs
erve
rs to
dist
ricts
?
If ye
s, to
how
man
y di
stric
ts.
9.Ha
ve th
e m
onth
ly re
porti
ng fo
rmat
for P
MSM
A be
en c
omm
unic
ated
to d
istric
ts?
Yes
N
o
10.
Has t
he st
ate
prep
ared
an
IEC
plan
for P
MSM
A?If
yes,
kin
dly
prov
ide
deta
ils Y
es
No
......
......
......
......
......
......
......
...
11.
Have
Sta
te R
MN
CH+A
par
tner
s bee
n in
volv
ed in
the
impl
emen
tatio
n of
PM
SMA?
If
yes,
kin
dly
prov
ide
deta
ils
Yes
N
o...
......
......
......
......
......
......
......
(atta
ch
com
men
ts in
sepa
rate
shee
t if
requ
ired)
12.
Rem
arks
/Com
men
ts (4
-5 p
oint
s, w
hich
, acc
ordi
ng to
you
can
pla
y a
sign
ifica
nt ro
le in
impr
ovin
g th
e im
plem
enta
tion
of
PMSM
A in
the
stat
e). A
lso
com
men
t if S
tate
has
intr
oduc
ed a
ny in
nova
tive
str
ateg
y fo
r im
plem
enti
ng P
MSM
A.
