KNOW YOUR SITE
I. Site Identification Information
Field marked with Red asterisk is compulsory to fill...............
Select your District.....
*
Ajmer
Alwar
Banswara
Baran
Barmer
Bharatpur
Bhilwara
Bikaner
Bundi
Chittorgarh
Churu
Dausa
Dholpur
Dungarpur
Ganganagar
Hanumangarh
Jaipur
Jaisalmer
Jalore
Jhalawar
Jhunjhunu
Jodhpur
Karauli
Kota
Nagaur
Pali
Pratapgarh
Rajsamand
Sawai Madhopur
Sikar
Sirohi
Tonk
Udaipur
Type of Hospital
*
Medical College
District Hospital
Sub District Hospital
CHC
Nature of Site:
*
Single Site
Sub Site (Part of Composite Site)
Site Code :
8 digit code
Sub Site number :
1 digit code
Name of Sentinel Site/Sub-site:
*
Name of Composite Site
Not applicable for single site
II. Details of ANC OPD Functioning
Number of days in a week that ANC clinic is functional in your hospital:
1 to 7
ANC OPD timings
New Case
From
New Case
To
Old Case
From
Old Case
To
All Case
From
All Case
To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Average daily ANC clinic attendance:
Who conducts the ANC clinic?
Gynaecologist
Other Doctor
Nurse
ANM
How many different doctors conduct ANC clinic in a week?:
What are the routine blood tests done for ANC attendees in your hospital ...(yes/ No)
YES/ NO
Syphilis
Haemoglobin/Hb
HIV
Malaria
Any Other tests done (Specify
Are these tests done routinely for every pregnant woman or only for those prescribed by the doctor?
All
Only for those prescribed by Doctor
When are routine test results returned to the pregnant woman?
Same Day
After Day(s)
During Next visit
How are routine test results issued?
Written on ANC card
Separate Report
Both
Is there a PPTCT centre functioning in your hospital?
YES
NO
Back
Next
How is it ensured that every pregnant woman attending the ANC clinic for check-up reaches PPTCT centre and gets tested for HIV?
Every pregnant woman is referred to PPTCT centre by doctor in ANC clinic, and the doctor verifies and ensures if HIV test results are available during next visit
PPTCT Counselor sits in/close to ANC clinic and ensures that every pregnant woman comes for HIV counseling after ANC check-up
Every pregnant woman is brought to PPTCT centre from ANC clinic by nurse/ out-reach worker/ hospital attendant (accompanied referral)
Every pregnant woman first comes to the PPTCT centre and goes to ANC clinic for check-up only after registration at PPTCT centre
ANC clinic & PPTCT centre work independently. Pregnant women come to PPTCT centre on their own. No specific procedures are employed.
How is blood collection for routine tests & HIV done?
Collected twice separately for HIV & routine tests
Collected only once and shared between PPTCTcentre for HIV & general lab for routine tests
Collected only once for HIV, no other tests aredone
When are HIV test results returned to the pregnant woman?
Same Day
After Day(s)
During Next Visit
How are HIV test results issued?
Written on ANC card
Separate Report
Both
Back
Next
III. Patient Flow of a Pregnant women on a Normal ANC OPD Day
Think of the normal steps that a pregnant woman goes through when she visits your hospital for ANC check up. The common steps are listed below. But, the order of steps in your hospital may be different from the order mentioned here. Mention numbers starting with ‘1’ in the empty boxes in the serial order of steps for new and old ANC case as followed in your hospital. If any step is not applicable to your hospital, leave it blank. STEPS OF PATIENT FLOW FOR A NEW/OLD ANC CASE
Current
Step Number for
NEW ANC Case
Current
Step Number for
OLD ANC Case
HSS
Step Number for NEW ANC Case
HSS
Step Number for NEW ANC Case
Entry into the Hospital
OPD/ANC registration counter/ Point where OPD / ANC card
is issued
ANC Clinic/ Point where doctor conducts antenatal check-up
PPTCT centre/ Point where HIV counseling is done
PPTCT centre/ Point where blood is collected for HIV testing
General testing lab/ Point where blood is collected for routine tests
PPTCT centre/ Point where HIV test results are issued
General testing lab/ Point where routine test results are issued
Any Other
Any Other
Any Other
Exit from hospital
Back
Next
IV. Distance & Documentation
(Mention the steps in the order of number you have given in table above. For each step, mention the distance from the previous point, documents maintained at that point & who fills the document. Examples of documents are ANC register, OPD/ANC card given to the pregnant woman, Requisition for routine tests, PPTCT register, Lab register, Routine test results/report, HIV test report, etc.)
Steps
Distance from Previous Point
Documentation at this step
Who fills the document ?
Step 1
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Step 2
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Step 3
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Step 4
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Step 5
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Step 6
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Step 7
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Step 8
a. Same room
b. Adjacent room
c. 3-4 rooms away in same corridor
d. Other part of same building
e. Other building
f. ……………………………………………………..
Submit
Should be Empty: