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Skill Assessment Template -Form Fill
Facility Identification
Q01
District name
Q02
District code
Q03
District Type
TSU
Non-TSU
Q04
Block name
Q05
Block code
Q06
Facility Name
Q07
Interview Details
Q07_1
Facility Observation Date
Q07_2
Interviewer Name
Q07_3
Interviewer Code
Q07_4
Result of interview
Completed
Refused
Partially completed
Postponed
Others (Specify)
Questions
A01
Name of the person interviewed
A02
Position of person interviewed?
SN
ANM
Others
A03
Do you know how to do an Interval IUCD insertion?
Yes
No
A04
Are you willing to demonstrate the skill
Yes
No
A05
Please ensure that the following items are available before starting the skill demonstration
A05_1
Zoe model
AVAILABLE
NOT AVAILABLE
A05_2
Cu IUCD 380 A (expiry date checked)
AVAILABLE
NOT AVAILABLE
A05_3
Or multi load 375 (expiry date checked)
AVAILABLE
NOT AVAILABLE
A05_4
Light source
AVAILABLE
NOT AVAILABLE
A05_5
Sim’s/Cusco’s vaginal Speculum
AVAILABLE
NOT AVAILABLE
A05_6
Sponge holding forceps
AVAILABLE
NOT AVAILABLE
A05_7
Cheatle’s forceps
AVAILABLE
NOT AVAILABLE
A05_8
Anterior vaginal wall retractor (if Sim’s speculum used)
AVAILABLE
NOT AVAILABLE
A05_9
Volsellum forceps curved / tenaculum
AVAILABLE
NOT AVAILABLE
A05_10
Uterine sound
AVAILABLE
NOT AVAILABLE
A05_11
Pair of scissors
AVAILABLE
NOT AVAILABLE
A05_12
Povidone iodine or chlorhexidine
AVAILABLE
NOT AVAILABLE
A05_13
Gloves
AVAILABLE
NOT AVAILABLE
A05_14
0.5 % chlorine solution
AVAILABLE
NOT AVAILABLE
A05_15
Tray for keeping instruments
AVAILABLE
NOT AVAILABLE
A05_16
Cotton swabs
AVAILABLE
NOT AVAILABLE
A06
Did the nurse review the client’s medical history?
Yes
No
A07
Did the nurse review the client’s reproductive history?
Yes
No
A08
Did the nurse instruct the client to empty her bladder?
Yes
No
A09
Did the nurse instruct the client to wash the perineal area?
Yes
No
A10
Did the nurse inform the client about the IUCD procedure?
Yes
No
A11
Did the nurse wash hands?
Yes
No
A12
Did the nurse dry her hands?
Yes
No
A13
Did the nurse palpates the abdomen?
Yes
No
A14
Did the nurse wash hands?
Yes
No
A15
Did the nurse dry her hands?
Yes
No
A16
Did the nurse wear sterile gloves?
Yes
No
A17
Did the nurse wear gloves in both hands?
Yes
No
A18
Did the nurse inspects the external genitalia?
Yes
No
A19
Do you find any potential problems in the examination?
Yes
No
A20
Did the nurse perform the Speculum exam?
Yes
No
A21
Did the nurse perform the bimanual exam?
Yes
No
A22
What examination was done first - Speculum or bimanual?
SPECULUM EXAM
BIMANUAL EXAM
NO SPECULUM EXAM
NO BIMANUAL EXAM
BOTH NOT DONE
A23
Did the nurse remind the client to let know if she feels pain?
Yes
No
A24
Did the nurse insert the speculum to visualize the cervix
Yes
No
A25
Did the nurse cleanses the cervical os with antiseptic?
Yes
No
A26
Did the nurse cleanses the vagina wall with antiseptic?
Yes
No
A27
Did the nurse gently grasp the cervix with tenaculum / Volsellum?
Yes
No
A28
Did the nurse apply gentle traction
Yes
No
A29
Did the nurse insert the sound using the “no touch technique”?
Yes
No
A30
Is the IUCD is Cu IUCD 380 A
Yes
No
A31
Did the health care provider open a sterile package of IUCD, from bottom by pulling back plastic cover approximately 1/3 upwards
Yes
No
A32
Did the health care provider hold the IUCD package, stabilize the IUCD and remove plunger rod, inserter tube and card from the package
Yes
No
A33
Did the nurse grasp the IUCD with a Kelly’s l forceps using the no touch technique?
Yes
No
A34
Can you tell me how far you should insert the Kelly’s forceps?
AGAINST BACK WALL OF UTERUS
OTHERS
DON’T KNOW
A35
Did the health care provider set the blue depth gauge to the measurement of the uterus
Yes
No
A36
Did the health care provider insert the loaded IUCD and release it into the uterus using withdrawl technique
Yes
No
A37
Did the health care provider remove the plunger rod
Yes
No
A38
Did the health care provider push the insertion tube upwards till a slight resistance is felt?
Yes
No
A39
Is the IUCD is Cu IUCD 375
Yes
No
A40
Did the health care provider grasp the insertion tube and the IUCD string together at the lower end of the tube
Yes
No
A41
Did the health care provider move the cervical guard to the measurement of the uterus
Yes
No
A42
Did the health care provider gently advance the loaded IUCD into the uterine cavity until the cervical guard touches the cervix or a slight resistance is felt
Yes
No
A43
Did the health care provider continue to apply gentle downward traction to the tenaculum/volsellum while removing the inserter tube from the cervical canal
Yes
No
A44
Did the health care provider withdraw the insertion tube until the IUCD strings can be seen?
Yes
No
A45
Did the nurse remove the sponge holding forceps from the cervix?
Yes
No
A46
Did the nurse remove the speculum from the cervix?
Yes
No
A47
Did the nurse place a hand on the lower part of the uterus with the finger towards the fundus?
Yes
No
A48
Did the nurse push the uterus upward?
Yes
No
A49
Did the nurse push the uterus backward?
Yes
No
A50
Did the nurse release the IUCD at the fundus?
Yes
No
A51
Did the nurse continue to stabilize the uterus with a hand on the abdomen?
Yes
No
A52
Did the nurse sweep the Kelly’s forceps to the side wall of the uterus?
Yes
No
A53
Did the nurse keep Kelly’s forceps slightly open while removing?
Yes
No
A54
Did the nurse stabilize the uterus until Kelly’s forceps were completely out of the uterus?
Yes
No
A55
Did the nurse use a sharp Mayo scissors to cut the IUCD strings to 3-4 cms
Yes
No
A56
Did the nurse examine the cervix?
Yes
No
A57
Can you tell me what will you do if the strings are visible and protruding from the cervix?
Remove,reload, reinsert
Others
Don’t know
A58
Did the nurse remove all the instruments?
Yes
No
A59
Did the nurse place all the instruments in 0.5% chlorine solutions for 10 minutes?
Yes
No
A60
Did the nurse discard all other waste materials (IUCD wrapper, gloves) as per IP protocol?
Yes
No
A61
Did Nurse wash both gloved hands in .5% chlorine solution?
Yes
No
A62
Did the nurse tell the mother about the successful insertion of the IUCD?
Yes
No
A63
Did nurse provide post insertion instructions for follow up?
Yes
No
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