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Practices Of Surgeons On Postpartum Template -Form Fill

Identification particulars
Q01

District Name

Q02

District Code

Q03

District type

Q04

Block Name

Q05

Block Code

Q06

Facility Name

Q07

Facility type

Q08

Provider designation

Q09

Facility Observation Date

Q10

Interviewer Name

Q11

Interviewer Code

Q12

Result of interview

Patient screening
A01

Name of the client

A02

Spouse’s name

A03

Address

A04

Contact details

A05

Marital Status

A06

Occupation of the client

A07

Religion

A08

Caste

A09

Education

A10

No of living children

A11

Age of youngest child

A12

Sex of the youngest child

Initial Assessment
B01

Did the health care provider initiate client’s record sheet?

B02

Did the health care provider ask about length of cycle

B03

Did the health care provider ask about duration of flow

B04

Did the health care provider ask about amount of flow

B05

Did the health care provider ask about regularity of periods

B06

Did the health care provider ask about dysmenorrhoea

B07

Did the health care provider ask about number of pregnancies

B08

Did the health care provider ask about date and mode of delivery

B09

Did the health care provider ask about number and date of abortion/MTP

B10

Did the health care provider ask about number and date of abortion/MTP

B11

Did the health care provider ask about if currently pregnant

B12

Did the health care provider ask if a contraceptive method ever used

B13

Did the health care provider ask about what was the last method used?

B14

Did the health care provider ask about the duration of use of last method?

B15

Did the health care provider measure pulse?

B16

Did the health care provider measure temperature?

B17

Did the health care provider measure blood pressure?

B18

Did the health care provider measure Hemoglobin?

B19

Did the health care provider take weight measurement?

B20

Did the health care provider perform an urine examination?

B21

Did the health care provider measure the respiratory rate?

B22

Was the pregnant woman asked about if she had/has severe headache?

B23

Was the pregnant woman asked about if she has /had blurred vision?

B24

Was the pregnant woman asked about if she has/had experienced fits/convulsions?

B25

Was the pregnant woman checked for vaginal bleeding?

B26

Was the pregnant woman asked about foul discharge per vagina?

B27

Was the pregnant woman asked if she has/had for severe abdominal pain?

B28

Was the pregnant woman asked about a history of heart disease or any other major illnesses?

B29

Was the pregnant woman asked if she had /has difficulty in breathing?

B30

Did the health care provider ask about Immunization status for tetanus

B31

Did the health care provider ask about any known drug allergies

B32

Did the health care provider ask about current medications and reason

B33

Did the health care provider perform an abdominal examination

B34

Did the health care provider perform a pelvic examination

B35

Did the health care provider perform a per speculum examination

B36

Did the health care provider perform a bimanual PV examination

PreProcedure Assessment
C01

Did the health care provider confirm that patient has not had food in the last 6 hours

C02

Did the health care provider confirm that patient has not had liquids in the last 4 hours

C03

Did the health care provider review the client’s history and physical examination results

C04

Did the health care provider verify the client’s informed choice and consent

C05

Did the health care provider take written consent? (check records and verify)

C06

Did the health care provider perform a physical examination to confirm clinical findings

C07

Did the health care provider ask client to empty bladder before entering OT

C08

Did the health care provider wear sterile gloves

C09

Did the health care provider perform a bimanual PV examination on the OT table

C10

Did the health care provider position the client in the dorsal supine position?

C11

Did the health care provider use an antiseptic soaked swab in a sponge forcep?

C12

Did the health care provider clean the umblicus

C13

Did the health care provider throw away the swab

C14

Did the health care provider use a second swab

C15

Did the health care provider start from the sub-umbilical incision area move progressively out from the umbilicus in circular motion

C16

Did the health care provider not bring the used swab back over a cleaned area?

C17

Did the health care provider swab atleast 1 to 2 cm circumference progressively in this manner to cover the whole abdomen

C18

Did the health care provider bring the used swab back over a cleaned area

C19

Did the health care provider use antispectic solution liberally for atleast 2 times?

C20

Did the health care provider wait for 2 minutes

C21

Did the health care provider let the excess antiseptic solution to drip and gather beneath the client’s body

C22

What antiseptic solution was used to clean the operative site

C23

Did the health care provider apply alcohol preparation to sensitive genitalia

C24

Did the health care provider wait for the area to dry

C25

Did the health care provider drape the area with sterile drape sheets

C26

Did the health care provider preselect the incision site?

C27

Did the health care provider use 2 10 ml syringes or 1 20 ml syringe loaded with 1% lignocaine

C28

Did the health care provider raise a small skin weal at the centre of the incision site

C29

Did the health care provider administer 3-5 ml of the local anesthetic

C30

Did the health care provider administer the local anesthetic on both sides of the incision line

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

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.

C33

Did the health care provider repeat on other side of incision line

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

C35

Did the health care provider withdraw the needle and place on a sterile or high-level disinfected tray

C36

Did the health care provider keep a small amount of lignocaine in the syringe for use on fascia, peritoneum and tubes

C37

Did the health care provider massage the skin gently to spread the anaesthetic into the tissues

C38

Did the health care provider wait 2–3 minutes for the anaesthetic to take effect

C39

Did the health care provider test the incision site for adequate anaesthesia using tissue forceps

C40

If client felt a pinch did the health care provider wait 2–3 minutes more and retest the incision site for pain

C41

Did the health service provider dispose of the gloves in a puncture proof container or plastic bag

C42

Did the health service provider dispose of the needles/broken vials in a puncture proof container or plastic bag

PreProcedure Assessment 2
D01

Was a pelvic exam performed right at the beginning?

D02

Did the health care provider put on sterile surgical gloves on both hands?

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

D04

Did the health care provider make a  skin incision approximately 2 – 3 cm long and open it only through the skin

D05

Was the cut transversal or 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?

D07

Did the health care provider dissect subcutaneous tissue until the fascia is viewed and exposed with retractors

D08

Did the health care provider incise the fascia?

D09

Did the health care provider place the table in a slight Trendelenburg position (20° or less)?

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

D11

Did the health care provider using scissors, incise the fascia transversely

D12

Did the health care provider separate rectus muscles in the midline (longitudinally) using blunt dissection with artery forceps

D13

Did the health care provider clean off pre peritoneal tissue if needed.

D14

Did the health care provider extend the fascial opening slightly beyond the skin incision on both sides

D15

Did the health care provider confirm identification of peritonium

D16

Did the health care provider identify and elevate the peritoneum by grasping it at two points with haemostatic forceps?

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

D18

Did the health care provider make a small opening high in the peritoneum with scissors

D19

Did the health care provider control bleeding from any vessel

D20

Did the health care provider confirm entry into the abdominal cavity?

D21

Did the surgical assistant gently place the retractors inside the abdomen to maximally expose the uterus and tubes

D22

Did the health care provider using gentle pressure on the abdomen, push the uterus toward the opposite side.

D23

Did the health care provider visualize the presence of uterine fundus underneath the incision line?

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

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

D26

After the tube has been identified, did the health care provider grasp it gently with a Babcock forceps

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

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.

D29

Did the health care provider position the Babcock forceps over an avascular portion of the mesosalpinx

D30

Did the health care provider keep the forceps in a vertical position, holding the tubal loop?

D31

Did the health care provider while grasping the mid-portion of tube, transfix the tube with chromic catgut 1-0?

D32

Did the health care provider make a loop of about 2-3 cms.?

D33

Did the health care provider tie the knots on both the sides of the tube?

D34

Did the health care provider cut the extra suture length ?

D35

Did the health care provider cut out one end of the loop and then the other with scissors?

D36

Did the health care provider ensure that at least 1 cm. of the tubal stump above the ligature has been left behind?

D37

Did the health care provider while still holding the ligature inspect the stump for haemostasis?

D38

Did the health care provider assure Hemostasis before the tube is released and returned to the abdominal cavity

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

D40

ON THE OTHER SIDE After the tube has been identified, did the health care provider grasp it gently with a Babcock forceps

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

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.

D43

ON THE OTHER SIDE Did the health care provider position the Babcock forceps over an avascular portion of the mesosalpinx

D44

ON THE OTHER SIDE Did the health care provider keep the forceps in a vertical position, holding the tubal loop?

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?

D46

ON THE OTHER SIDE Did the health care provider make a loop of about 2-3 cms.?

D47

ON THE OTHER SIDE Did the health care provider tie the knots on both the sides of the tube?

D48

ON THE OTHER SIDE Did the health care provider cut the extra suture length ?

D49

ON THE OTHER SIDE Did the health care provider cut out one end of the loop and then the other with scissors?

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?

D51

ON THE OTHER SIDE Did the health care provider while still holding the ligature inspect the stump for haemostasis?

D52

ON THE OTHER SIDE Did the health care provider assure Hemostasis before the tube is released and returned to the abdominal cavity

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

D54

Did the surgical assistant keep the incision open with retractors during the operation?

D55

Did the surgical assistant adjust the retractors as needed during the procedure?

D56

Before closing the abdomen, did the health care provider visually explore the surgical area to exclude the possibility of any injury or bleeding

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

D58

Did the health care provider close the skin with interrupted stitches, using either the same absorbable suture or non-absorbable suture number 0

D59

Did the health care provider dry the surrounding area

D60

Did the health care dress the wound when dry

D61

During the whole procedure was communication with the client maintained?

D62

How many staff was present during the procedure?

D63

Did auditory privacy maintained during the procedure?

D64

Did visual privacy maintained during the procedure?

D65

Type of mini-laparotomy performed

D66

How was client shifted from OT to recovery area?

Post Procedure Assessment
E01

Was the client’s record received from the operating theatre

E02

Was the client made as comfortable as possible (handle the woman gently when moving her).

E03

Was it made sure that an over sedated client was never left unattended.

E04

Was the client’s blood pressure monitored every 15 minutes

E04_1

15 min

E04_2

30 min

E04_3

45 min

E04_4

60 min

E05

Was it recorded in the client’s record

E06

Was the client’s respiration monitored every 15 minutes

E06_1

15 min

E06_2

30 min

E06_3

45 min

E06_4

60 min

E07

Was it recorded in the client’s record

E08

Was the client’s pulse monitored every 15 minutes.

E08_1

15 min

E08_2

30 min

E08_3

45 min

E08_4

60 min

E09

Was it recorded in the client’s record

E10

Was it recorded in the client’s record

E11

Was the client’s blood pressure monitored every hour for 4 hours

E11_1

1 = hour

E11_2

2 = hour

E11_3

3 hour

E11_4

4 hour

E12

Was it recorded in the client’s record

E13

Was the client’s respiration monitored every hour for 4 hours

E13_1

1 = hour

E13_2

2 = hour

E13_3

3 hour

E13_4

4 hour

E14

Was it recorded in the client’s record

E15

Was the client’s pulse monitored every hour for 4 hours

E15_1

1 = hour

E15_2

2 = hour

E15_3

3 hour

E15_4

4 hour

E16

Was it recorded in the client’s record

E17

Was the client’s surgical dressing checked for oozing or bleeding

E18

If the client is bleeding, did the surgeon check for possible injury to the cervix that may have been caused by the vulsellum

E19

Was the client administered drugs or treatment for symptoms according to the doctor’s orders

E20

Was the client provided water, tea and fruit juices when the client feels comfortable

E21

Was the client’s record form completed

E22

After home many hours after the procedure was the client discharged

E23

Before discharge, did the client checked for able to pass urine

E24

Before discharge, did the client checked for fully awake

E25

Before discharge, did the client checked for able to walk

E26

Before discharge, did the client checked for absence of vomiting

E27

Before discharge, did the client checked for absence of vaginal bleeding

E28

Was the client informed to rest for 2 days

E29

Was the client informed to avoid vigorous work for a week

E30

Was the client informed to avoid heavy lifting for a week

E31

Was the client given instruction to keep the incision dry and clean till stiches are removed

E32

Was the client given instruction when to return for stich removal

E33

Was the client given instruction to avoid rubbing the incision for a week

E34

Was the client given instruction to avoid sex for a week

E35

Was the client given instruction to about the follow up schedule

E35_1

Within 48 hours by FLW

E35_2

Stich removal on 8th day

E35_3

Visit to facility after a month

E36

Was the client given instruction on possible complications

E37

Was the client informed where to go for routine and emergency follow up

E38

Was the client/family members given an opportunity to ask questions

E39

Was it ensured that the client/family members understood the instructions

E40

Was the client given the discharge card

E40A

Was the client given the sterilization certificate

E41

Was the client provided with antibiotics/medicines/ prescription required?

OT Process
F01

Were clean, loose-fitting cloths worn by the clients

F02

Did the theatre personnel/those involved in surgery change into the following theatre attire?

F02A

Surgeon

F02A_1

Gown

F02A_2

Cap

F02A_3

Mask

F02A_4

Theatre footwear

F02B

Other personnel

F02B_1

Gown

F02B_2

Cap

F02B_3

Mask

F02B_4

Theatre footwear

F03

Did the surgeon scrub before starting?

F04

For approximately how many minutes did the surgeon scrub using soap?

F05

Was the mask kept over the bridge of the nose at all times by the surgeon?

F06

Were new sterile gloves worn by the surgeon before starting the procedure?

F07

Were new sterile gloves worn by the surgeon on both hands before starting the procedure?

F08

Did the surgeon leave the OT at any time between cases?

F09

Did the surgeon/assistant change his/her shoes while going out?

F10

Did he/she change his/her gown on returning?

F11

Did he/she scrub on returning?

F12

After performing how many cases did the surgeon scrub again?

F13

Did the OT technician change into the following theatre attire?

F13_1

Gown

F13_2

Cap

F13_3

Mask

F13_4

Theatre footwear

F14

Did the OT technician scrub before starting?

F15

Was the mask kept over the bridge of the nose at all times by the OT technician?

F16

Were the new sterile gloves worn by the surgeon before starting each procedure?

F17

Did the OT technician leave the OT at any time between cases?

F18

Did he/she change his/her gown on returning?

F19

Did he/she scrub on returning?

F20

After performing how many cases did the OT technician scrub again?

F21

Were all the used unwashed instruments in 0.5% chlorine solution for 10 minutes for decontamination.

OT Infrastructure & Supplies
G01

Are the following surgical instruments used for sterilization in working condition?

G01_1

Gas cylinders: N2O

G01_2

Gas cylinders: Air/Any other

G01_3

Boyles apparatus

G01_4

Stethoscope

G01_5

Blood pressure instrument

G01_6

Laryngoscope

G01_7

Laryngoscope with cells

G01_8

Endotracheal tubes size 6, 6.5, 7, 7.5, 8.

G01_9

Laryngeal mask airways size 3, 4,5

G01_10

Venesection instrument

G01_11

Suction machine with tubing and two streps

G01_12

Flexible suction catheter

G01_13

Nasopharyngeal airways size 28 &30

G01_14

Tourniquet

G01_15

Foleys catheter (size 16& 18) with drainage bag

G01_16

Emesis basin

G01_17

Blanket

G01_18

Tubing with oxygen nipples

G01_19

Oxygen cylinder with reducing valve and flow meter

G01_20

Vein flow

G01_21

Folded gauze pieces

G01_22

Veres needle

G01_23

Minilap kit

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

H06

Address

H07

Village

H08

Block Name

H09

Phone number

H10

ASHA Name

H11

ASHA Phone Number