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Practices Of Surgeons On Postpartum Template -Form Fill
Identification particulars
Q01
District Name
Q02
District Code
Q03
District type
TSU
Non-TSU
Q04
Block Name
Q05
Block Code
Q06
Facility Name
Q07
Facility type
DH/DCH/DWH
SDH
CHC-FRU
CHC Non-FRU
BPHC/PHC
Others
Q08
Provider designation
Doctor
Nurse
ANM
Family Planning Counsellor
Q09
Facility Observation Date
Q10
Interviewer Name
Q11
Interviewer Code
Q12
Result of interview
Completed
Refused
Partially completed
Postponed
Others (Specify)
Patient screening
A01
Name of the client
A02
Spouse’s name
A03
Address
A04
Contact details
A05
Marital Status
CURENTLY MARRIED
SEPERATED
WIDOW
OTHERS
A06
Occupation of the client
A07
Religion
HINDU
MUSLIM
OTHERS
A08
Caste
GENERAL
OTHER BACKWARD CASTE
SCHEDULED CASTE
SCHEDULED TRIBE
NO CASTE
A09
Education
CAN READ AND WRITE
CAN NOT READ AND WRITE
A10
No of living children
A11
Age of youngest child
A12
Sex of the youngest child
MALE
FEMALE
Initial Assessment
B01
Did the health care provider initiate client’s record sheet?
Yes
No
B02
Did the health care provider ask about length of cycle
Yes
No
B03
Did the health care provider ask about duration of flow
Yes
No
B04
Did the health care provider ask about amount of flow
Yes
No
B05
Did the health care provider ask about regularity of periods
Yes
No
B06
Did the health care provider ask about dysmenorrhoea
Yes
No
B07
Did the health care provider ask about number of pregnancies
Yes
No
B08
Did the health care provider ask about date and mode of delivery
Yes
No
B09
Did the health care provider ask about number and date of abortion/MTP
Yes
No
B10
Did the health care provider ask about number and date of abortion/MTP
Yes
No
B11
Did the health care provider ask about if currently pregnant
Yes
No
B12
Did the health care provider ask if a contraceptive method ever used
Yes
No
B13
Did the health care provider ask about what was the last method used?
Yes
No
B14
Did the health care provider ask about the duration of use of last method?
Yes
No
B15
Did the health care provider measure pulse?
Yes
No
B16
Did the health care provider measure temperature?
Yes
No
B17
Did the health care provider measure blood pressure?
Yes
No
B18
Did the health care provider measure Hemoglobin?
Yes
No
B19
Did the health care provider take weight measurement?
Yes
No
B20
Did the health care provider perform an urine examination?
Yes
No
B21
Did the health care provider measure the respiratory rate?
Yes
No
B22
Was the pregnant woman asked about if she had/has severe headache?
Yes
No
B23
Was the pregnant woman asked about if she has /had blurred vision?
Yes
No
B24
Was the pregnant woman asked about if she has/had experienced fits/convulsions?
Yes
No
B25
Was the pregnant woman checked for vaginal bleeding?
Yes
No
B26
Was the pregnant woman asked about foul discharge per vagina?
Yes
No
B27
Was the pregnant woman asked if she has/had for severe abdominal pain?
Yes
No
B28
Was the pregnant woman asked about a history of heart disease or any other major illnesses?
Yes
No
B29
Was the pregnant woman asked if she had /has difficulty in breathing?
Yes
No
B30
Did the health care provider ask about Immunization status for tetanus
Yes
No
B31
Did the health care provider ask about any known drug allergies
Yes
No
B32
Did the health care provider ask about current medications and reason
Yes
No
B33
Did the health care provider perform an abdominal examination
Yes
No
B34
Did the health care provider perform a pelvic examination
Yes
No
B35
Did the health care provider perform a per speculum examination
Yes
No
B36
Did the health care provider perform a bimanual PV examination
Yes
No
PreProcedure Assessment
C01
Did the health care provider confirm that patient has not had food in the last 6 hours
Yes
No
C02
Did the health care provider confirm that patient has not had liquids in the last 4 hours
Yes
No
C03
Did the health care provider review the client’s history and physical examination results
Yes
No
C04
Did the health care provider verify the client’s informed choice and consent
Yes
No
C05
Did the health care provider take written consent? (check records and verify)
Yes
No
C06
Did the health care provider perform a physical examination to confirm clinical findings
Yes
No
C07
Did the health care provider ask client to empty bladder before entering OT
Yes
No
C08
Did the health care provider wear sterile gloves
Yes
No
C09
Did the health care provider perform a bimanual PV examination on the OT table
Yes
No
C10
Did the health care provider position the client in the dorsal supine position?
Yes
No
C11
Did the health care provider use an antiseptic soaked swab in a sponge forcep?
Yes
No
C12
Did the health care provider clean the umblicus
Yes
No
C13
Did the health care provider throw away the swab
Yes
No
C14
Did the health care provider use a second swab
Yes
No
C15
Did the health care provider start from the sub-umbilical incision area move progressively out from the umbilicus in circular motion
Yes
No
C16
Did the health care provider not bring the used swab back over a cleaned area?
Yes
No
C17
Did the health care provider swab atleast 1 to 2 cm circumference progressively in this manner to cover the whole abdomen
Yes
No
C18
Did the health care provider bring the used swab back over a cleaned area
Yes
No
C19
Did the health care provider use antispectic solution liberally for atleast 2 times?
Yes
No
C20
Did the health care provider wait for 2 minutes
Yes
No
C21
Did the health care provider let the excess antiseptic solution to drip and gather beneath the client’s body
Yes
No
C22
What antiseptic solution was used to clean the operative site
IODOPHOR (POVIDONE IODINE)
CHLORHEXIDINE GLUCONATE
OTHERS
C23
Did the health care provider apply alcohol preparation to sensitive genitalia
Yes
No
C24
Did the health care provider wait for the area to dry
Yes
No
C25
Did the health care provider drape the area with sterile drape sheets
Yes
No
C26
Did the health care provider preselect the incision site?
Yes
No
C27
Did the health care provider use 2 10 ml syringes or 1 20 ml syringe loaded with 1% lignocaine
Yes
No
C28
Did the health care provider raise a small skin weal at the centre of the incision site
Yes
No
C29
Did the health care provider administer 3-5 ml of the local anesthetic
Yes
No
C30
Did the health care provider administer the local anesthetic on both sides of the incision line
Yes
No
C31
Did the health care provider starting at the centre of the incision line and without withdrawing the needle, insert needle into the fascia at a 45° angle, with the needle directed slightly superior to the incision line
Yes
No
C32
Did the health care provider aspirate to ensure the needle is not in a blood vessel, then withdraw the needle slowly while injecting 3–5 ml of lignocaine.
Yes
No
C33
Did the health care provider repeat on other side of incision line
Yes
No
C34
Did the health care provider insert the needle straight down through the rectus sheath to the peritoneum till a loss of resistance or give away is felt, aspirate again at this point to be sure that needle is not in a blood vessel and inject 1–2 ml of anaesthetic into the pre-peritoneal tissue
Yes
No
C35
Did the health care provider withdraw the needle and place on a sterile or high-level disinfected tray
Yes
No
C36
Did the health care provider keep a small amount of lignocaine in the syringe for use on fascia, peritoneum and tubes
Yes
No
C37
Did the health care provider massage the skin gently to spread the anaesthetic into the tissues
Yes
No
C38
Did the health care provider wait 2–3 minutes for the anaesthetic to take effect
Yes
No
C39
Did the health care provider test the incision site for adequate anaesthesia using tissue forceps
Yes
No
C40
If client felt a pinch did the health care provider wait 2–3 minutes more and retest the incision site for pain
Yes
No
C41
Did the health service provider dispose of the gloves in a puncture proof container or plastic bag
YES
NO
WAS NOT WEARING GLOVES
C42
Did the health service provider dispose of the needles/broken vials in a puncture proof container or plastic bag
YES
NO
WAS NOT WEARING GLOVES
PreProcedure Assessment 2
D01
Was a pelvic exam performed right at the beginning?
Yes
No
D02
Did the health care provider put on sterile surgical gloves on both hands?
Yes
No
D03
Did the health care provider insert uterine elevator into the vagina, through the cervix, and into the uterus to raise the tubes to bring them closer to the incision where the uterus is not palpable per-abdominally
Yes
No
D04
Did the health care provider make a skin incision approximately 2 – 3 cm long and open it only through the skin
Yes
No
D05
Was the cut transversal or vertical?
TRANSVERSE
VERTICAL
D06
Did the health care provider using a forceps or retractors, bluntly dissect the subcutaneous fat gently and precisely, to minimize tissue trauma and bleeding?
Yes
No
D07
Did the health care provider dissect subcutaneous tissue until the fascia is viewed and exposed with retractors
Yes
No
D08
Did the health care provider incise the fascia?
Yes
No
D09
Did the health care provider place the table in a slight Trendelenburg position (20° or less)?
Yes
No
D10
Did the health care provider grasp and elevate the fascia with Allis forceps in the midline of the incision at the inferior and superior portion
Yes
No
D11
Did the health care provider using scissors, incise the fascia transversely
Yes
No
D12
Did the health care provider separate rectus muscles in the midline (longitudinally) using blunt dissection with artery forceps
Yes
No
D13
Did the health care provider clean off pre peritoneal tissue if needed.
Yes
No
D14
Did the health care provider extend the fascial opening slightly beyond the skin incision on both sides
Yes
No
D15
Did the health care provider confirm identification of peritonium
Yes
No
D16
Did the health care provider identify and elevate the peritoneum by grasping it at two points with haemostatic forceps?
Yes
No
D17
Did the health care provider, check that the bowel, bladder or omentum has not been grasped inadvertently with the peritoneum by palpating the tissue between thumb and finger
Yes
No
D18
Did the health care provider make a small opening high in the peritoneum with scissors
Yes
No
D19
Did the health care provider control bleeding from any vessel
Yes
No
D20
Did the health care provider confirm entry into the abdominal cavity?
Yes
No
D21
Did the surgical assistant gently place the retractors inside the abdomen to maximally expose the uterus and tubes
Yes
No
D22
Did the health care provider using gentle pressure on the abdomen, push the uterus toward the opposite side.
Yes
No
D23
Did the health care provider visualize the presence of uterine fundus underneath the incision line?
Yes
No
D24
Did the health care provider with retractors in place gently reposition the incision over the right or left adnexa by manipulating the uterus through the abdominal wall
Yes
No
D25
Did the health care provider use uterine elevator to raise the tubes to bring them closer to the incision where the uterus is not palpable per-abdominally
Yes
No
D26
After the tube has been identified, did the health care provider grasp it gently with a Babcock forceps
Yes
No
D27
Did the health care provider confirm the identity of the tube by following it to the fimbriated end (using the Babcock forceps with one hand and a non-toothed dissecting forceps with the other) and pulling the tube out gently until the fimbria can be seen
Yes
No
D28
Did the health care provider use a Babcock forceps to grasp and elevate a 2-cms loop of fallopian tube at its midsection (the isthamic portion), approximately 2 = to 3 cm from the cornual portion of the tube.
Yes
No
D29
Did the health care provider position the Babcock forceps over an avascular portion of the mesosalpinx
Yes
No
D30
Did the health care provider keep the forceps in a vertical position, holding the tubal loop?
Yes
No
D31
Did the health care provider while grasping the mid-portion of tube, transfix the tube with chromic catgut 1-0?
Yes
No
D32
Did the health care provider make a loop of about 2-3 cms.?
Yes
No
D33
Did the health care provider tie the knots on both the sides of the tube?
Yes
No
D34
Did the health care provider cut the extra suture length ?
Yes
No
D35
Did the health care provider cut out one end of the loop and then the other with scissors?
Yes
No
D36
Did the health care provider ensure that at least 1 cm. of the tubal stump above the ligature has been left behind?
Yes
No
D37
Did the health care provider while still holding the ligature inspect the stump for haemostasis?
Yes
No
D38
Did the health care provider assure Hemostasis before the tube is released and returned to the abdominal cavity
Yes
No
D39
ON THE OTHER SIDE Did the health care provider use uterine to raise the tubes to bring them closer to the incision where the uterus is not palpable per-abdominally
Yes
No
D40
ON THE OTHER SIDE After the tube has been identified, did the health care provider grasp it gently with a Babcock forceps
Yes
No
D41
ON THE OTHER SIDE Did the health care provider confirm the identity of the tube by following it to the fimbriated end (using the Babcock forceps with one hand and a non-toothed dissecting forceps with the other) and pulling the tube out gently until the fimbria can be seen
Yes
No
D42
ON THE OTHER SIDE Did the health care provider use a Babcock forceps to grasp and elevate a 2-cms loop of fallopian tube at its midsection (the isthamic portion), approximately 2 = to 3 cm from the cornual portion of the tube.
Yes
No
D43
ON THE OTHER SIDE Did the health care provider position the Babcock forceps over an avascular portion of the mesosalpinx
Yes
No
D44
ON THE OTHER SIDE Did the health care provider keep the forceps in a vertical position, holding the tubal loop?
Yes
No
D45
ON THE OTHER SIDE Did the health care provider while grasping the mid-portion of tube, transfix the tube with chromic catgut 1-0?
Yes
No
D46
ON THE OTHER SIDE Did the health care provider make a loop of about 2-3 cms.?
Yes
No
D47
ON THE OTHER SIDE Did the health care provider tie the knots on both the sides of the tube?
Yes
No
D48
ON THE OTHER SIDE Did the health care provider cut the extra suture length ?
Yes
No
D49
ON THE OTHER SIDE Did the health care provider cut out one end of the loop and then the other with scissors?
Yes
No
D50
ON THE OTHER SIDE Did the health care provider ensure that at least 1 cm. of the tubal stump above the ligature has been left behind?
Yes
No
D51
ON THE OTHER SIDE Did the health care provider while still holding the ligature inspect the stump for haemostasis?
Yes
No
D52
ON THE OTHER SIDE Did the health care provider assure Hemostasis before the tube is released and returned to the abdominal cavity
Yes
No
D53
After both fallopian tubes have been occluded and put back to the abdomen, did the health care provider change the table to its initial horizontal position if the Trendelenburg position was used
YES
NO
TRENDELENBURG POSITION NOT USED
D54
Did the surgical assistant keep the incision open with retractors during the operation?
Yes
No
D55
Did the surgical assistant adjust the retractors as needed during the procedure?
Yes
No
D56
Before closing the abdomen, did the health care provider visually explore the surgical area to exclude the possibility of any injury or bleeding
Yes
No
D57
While grasping both sides of the anterior rectus sheath, did the health care provider starting at one end of the incision, close the anterior rectus sheath using a continuous (running stitch) suture with the same suture used for ligating the tubes
Yes
No
D58
Did the health care provider close the skin with interrupted stitches, using either the same absorbable suture or non-absorbable suture number 0
Yes
No
D59
Did the health care provider dry the surrounding area
Yes
No
D60
Did the health care dress the wound when dry
Yes
No
D61
During the whole procedure was communication with the client maintained?
Yes
No
D62
How many staff was present during the procedure?
D63
Did auditory privacy maintained during the procedure?
Yes
No
D64
Did visual privacy maintained during the procedure?
Yes
No
D65
Type of mini-laparotomy performed
SUB-UMBILICAL APPROACH
SUPRA PUBIC
D66
How was client shifted from OT to recovery area?
Yes
No
Post Procedure Assessment
E01
Was the client’s record received from the operating theatre
Yes
No
E02
Was the client made as comfortable as possible (handle the woman gently when moving her).
Yes
No
E03
Was it made sure that an over sedated client was never left unattended.
Yes
No
E04
Was the client’s blood pressure monitored every 15 minutes
E04_1
15 min
Yes
No
E04_2
30 min
Yes
No
E04_3
45 min
Yes
No
E04_4
60 min
Yes
No
E05
Was it recorded in the client’s record
Yes
No
E06
Was the client’s respiration monitored every 15 minutes
E06_1
15 min
Yes
No
E06_2
30 min
Yes
No
E06_3
45 min
Yes
No
E06_4
60 min
Yes
No
E07
Was it recorded in the client’s record
Yes
No
E08
Was the client’s pulse monitored every 15 minutes.
E08_1
15 min
Yes
No
E08_2
30 min
Yes
No
E08_3
45 min
Yes
No
E08_4
60 min
Yes
No
E09
Was it recorded in the client’s record
Yes
No
E10
Was it recorded in the client’s record
Yes
No
E11
Was the client’s blood pressure monitored every hour for 4 hours
E11_1
1 = hour
Yes
No
E11_2
2 = hour
Yes
No
E11_3
3 hour
Yes
No
E11_4
4 hour
Yes
No
E12
Was it recorded in the client’s record
Yes
No
E13
Was the client’s respiration monitored every hour for 4 hours
E13_1
1 = hour
Yes
No
E13_2
2 = hour
Yes
No
E13_3
3 hour
Yes
No
E13_4
4 hour
Yes
No
E14
Was it recorded in the client’s record
Yes
No
E15
Was the client’s pulse monitored every hour for 4 hours
E15_1
1 = hour
Yes
No
E15_2
2 = hour
Yes
No
E15_3
3 hour
Yes
No
E15_4
4 hour
Yes
No
E16
Was it recorded in the client’s record
Yes
No
E17
Was the client’s surgical dressing checked for oozing or bleeding
Yes
No
E18
If the client is bleeding, did the surgeon check for possible injury to the cervix that may have been caused by the vulsellum
Yes
No
E19
Was the client administered drugs or treatment for symptoms according to the doctor’s orders
Yes
No
E20
Was the client provided water, tea and fruit juices when the client feels comfortable
Yes
No
E21
Was the client’s record form completed
Yes
No
E22
After home many hours after the procedure was the client discharged
E23
Before discharge, did the client checked for able to pass urine
Yes
No
E24
Before discharge, did the client checked for fully awake
Yes
No
E25
Before discharge, did the client checked for able to walk
Yes
No
E26
Before discharge, did the client checked for absence of vomiting
Yes
No
E27
Before discharge, did the client checked for absence of vaginal bleeding
Yes
No
E28
Was the client informed to rest for 2 days
Yes
No
E29
Was the client informed to avoid vigorous work for a week
Yes
No
E30
Was the client informed to avoid heavy lifting for a week
Yes
No
E31
Was the client given instruction to keep the incision dry and clean till stiches are removed
Yes
No
E32
Was the client given instruction when to return for stich removal
Yes
No
E33
Was the client given instruction to avoid rubbing the incision for a week
Yes
No
E34
Was the client given instruction to avoid sex for a week
Yes
No
E35
Was the client given instruction to about the follow up schedule
E35_1
Within 48 hours by FLW
Yes
No
E35_2
Stich removal on 8th day
Yes
No
E35_3
Visit to facility after a month
Yes
No
E36
Was the client given instruction on possible complications
Yes
No
E37
Was the client informed where to go for routine and emergency follow up
Yes
No
E38
Was the client/family members given an opportunity to ask questions
Yes
No
E39
Was it ensured that the client/family members understood the instructions
Yes
No
E40
Was the client given the discharge card
Yes
No
E40A
Was the client given the sterilization certificate
Yes
No
E41
Was the client provided with antibiotics/medicines/ prescription required?
Yes
No
OT Process
F01
Were clean, loose-fitting cloths worn by the clients
Yes
No
F02
Did the theatre personnel/those involved in surgery change into the following theatre attire?
F02A
Surgeon
F02A_1
Gown
Yes
No
F02A_2
Cap
Yes
No
F02A_3
Mask
Yes
No
F02A_4
Theatre footwear
Yes
No
F02B
Other personnel
F02B_1
Gown
Yes
No
F02B_2
Cap
Yes
No
F02B_3
Mask
Yes
No
F02B_4
Theatre footwear
Yes
No
F03
Did the surgeon scrub before starting?
Yes
No
F04
For approximately how many minutes did the surgeon scrub using soap?
<3min
3-5min
>5min
F05
Was the mask kept over the bridge of the nose at all times by the surgeon?
Yes
No
F06
Were new sterile gloves worn by the surgeon before starting the procedure?
Yes
No
F07
Were new sterile gloves worn by the surgeon on both hands before starting the procedure?
Yes
No
F08
Did the surgeon leave the OT at any time between cases?
Yes
No
F09
Did the surgeon/assistant change his/her shoes while going out?
Yes
No
F10
Did he/she change his/her gown on returning?
Yes
No
F11
Did he/she scrub on returning?
Yes
No
F12
After performing how many cases did the surgeon scrub again?
DID NOT RESCRUB
1 CASE
2-4 CASE
5 CASES OR MORE
F13
Did the OT technician change into the following theatre attire?
F13_1
Gown
Yes
No
F13_2
Cap
Yes
No
F13_3
Mask
Yes
No
F13_4
Theatre footwear
Yes
No
F14
Did the OT technician scrub before starting?
Yes
No
F15
Was the mask kept over the bridge of the nose at all times by the OT technician?
Yes
No
F16
Were the new sterile gloves worn by the surgeon before starting each procedure?
Yes
No
F17
Did the OT technician leave the OT at any time between cases?
Yes
No
F18
Did he/she change his/her gown on returning?
Yes
No
F19
Did he/she scrub on returning?
Yes
No
F20
After performing how many cases did the OT technician scrub again?
DID NOT RESCRUB
1 CASE
2-4 CASE
5 CASES OR MORE
F21
Were all the used unwashed instruments in 0.5% chlorine solution for 10 minutes for decontamination.
Yes
No
OT Infrastructure & Supplies
G01
Are the following surgical instruments used for sterilization in working condition?
G01_1
Gas cylinders: N2O
Yes
No
G01_2
Gas cylinders: Air/Any other
Yes
No
G01_3
Boyles apparatus
Yes
No
G01_4
Stethoscope
Yes
No
G01_5
Blood pressure instrument
Yes
No
G01_6
Laryngoscope
Yes
No
G01_7
Laryngoscope with cells
Yes
No
G01_8
Endotracheal tubes size 6, 6.5, 7, 7.5, 8.
Yes
No
G01_9
Laryngeal mask airways size 3, 4,5
Yes
No
G01_10
Venesection instrument
Yes
No
G01_11
Suction machine with tubing and two streps
Yes
No
G01_12
Flexible suction catheter
Yes
No
G01_13
Nasopharyngeal airways size 28 &30
Yes
No
G01_14
Tourniquet
Yes
No
G01_15
Foleys catheter (size 16& 18) with drainage bag
Yes
No
G01_16
Emesis basin
Yes
No
G01_17
Blanket
Yes
No
G01_18
Tubing with oxygen nipples
Yes
No
G01_19
Oxygen cylinder with reducing valve and flow meter
Yes
No
G01_20
Vein flow
Yes
No
G01_21
Folded gauze pieces
Yes
No
G01_22
Veres needle
Yes
No
G01_23
Minilap kit
Yes
No
CLIENT DETAILS
H01
Name of the client
H02
Age of the client
H03
Total number of children of client
H04
Age of youngest child
H05
Sex of youngest child
MALE
FEMALE
H06
Address
H07
Village
H08
Block Name
H09
Phone number
H10
ASHA Name
H11
ASHA Phone Number
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