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Observation Template -Form Fill
Facility Identification
Q01
Name of the Facility
Q02
Type of Facility
Q03
Name of the Investigator
Q04
Name of the district
Q05
Name of the block
Observation
A01
Does the facility have an examination room/Triage area?
Yes
No
A02
Number of beds available in the triage area?
Yes
No
A03
Are there screens surrounding the bed for privacy?
Yes
No
A04
Is there seating arrangement for the people accompanying the woman?
Yes
No
A05
Is there a table for nurse to work on?
Yes
No
A06
Tick the logistics and equipment available for the triage area?
Dipsticks for urine protein and sugar
Stethoscope
Foetal Doppler
Examination Table
Foot Step
Wall clock with seconds hand
Measuring Tape
Washbasin
Refrigerator
Telephone
Wheelchair
Stretcher
Adult weighing scale
PPE
Chair for nurse/doctor to sit
Front opening gowns for all pregnant women
A07
Is all 3 tray available in triage?
Delivery Tray
Emergency Drug Tray
Examination Tray
A08
Is there a storage cabinet for the supplies?
Yes
No
A09
Availability of case sheet
Yes
No
A10
Are there colour- segregated waste bins for waste disposal?
Yellow
Red
Blue
Black
A11
Is there proper lighting in the triage area?
Yes
No
A12
Is the area well ventilated?
Yes
No
A13
Is the nurse taking history of the woman?
Yes
No
A14
Is the nurse measuring the following:
A14_1
Pulse of the woman
Yes
No
A14_2
Temperature of the woman
Yes
No
A14_3
Heart rate of the woman
Yes
No
A14_4
Heart rate of the fetus
Yes
No
A14_5
Blood pressure of the woman
Yes
No
A14_6
Hb of the woman
Yes
No
A14_7
Was the nurse wearing gloves during examination?
Yes
No
A14_8
How is Nurse’s behavior towards the woman?
Yes
No
A14_9
How is the Nurse’s behavior towards the people accompanying the woman?
Yes
No
Observation tool Neonates – Triage area/Examination tool
B01
Does the facility have an examination room/Triage area?
Yes
No
B02
Number of beds available in the triage area?
Yes
No
B03
Are there screens surrounding the bed for privacy?
Yes
No
B04
Is there seating arrangement for the people accompanying the woman?
Yes
No
B05
Is there a table for nurse to work on?
Yes
No
B06
Tick the logistics and equipment available for the triage area?
Digital Hb meter
Digital BP apparatus
Digital thermometer
Dipsticks for urine protein and sugar
Stethoscope
Foetal Doppler
Examination Table
Foot Step
Wall clock with seconds hand
Measuring Tape
Washbasin
Refrigerator
Telephone
Wheelchair
Stretcher
Adult weighing scale
PPE
Chair for nurse/doctor to sit
Front opening gowns for all pregnant women
B07
Are all 3 trays available in triage?
Delivery Tray
Emergency Drug Tray
Examination Tray
B08
Tick the items available for new-born resuscitation
Ambu Bag
Newborn mask size
Newborn mask size 0
Mucus extractor
B09
Is there a storage cabinet for the supplies?
Yes
No
B10
Availability of case sheet?
Yes
No
B11
Are there segregated waste bins for waste disposal?
Yes
No
B12
Is there proper lighting in the triage area?
Yes
No
B13
Is the area well ventilated?
Yes
No
B14
Is the nurse taking history of the neonate?
Yes
No
B15
Is the nurse measuring the following:
B15_1
Pulse
Yes
No
B15_2
Temperature
Yes
No
B15_3
Heart rate
Yes
No
B15_4
Blood pressure
Yes
No
B15_5
Hb
Yes
No
B16
Did the nurse assess the following
B16_1
Airway
Yes
No
B16_2
Breathing
Yes
No
B16_3
Circulation
Yes
No
B16_4
Coma
Yes
No
B16_5
Convulsion
Yes
No
B16_6
Dehydration
Yes
No
B17
Was the nurse wearing gloves while doing the examination?
Yes
No
B18
How is Nurse’s behavior towards the neonate?
Yes
No
B19
How is the Nurse’s behavior towards the people accompanying the neonate?
Yes
No
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