Monthly Service Delivery Reporting format

Primary Health Centre (PHC) FORMAT

State : District :
Sub district/Block / Health Block :
Name of Health Facility:
Facility Type: 24x7 AAM-PHC (R): PHC-AAM (R): 24x7 UPHC-AAM:
UPHC-AAM: UPHC/ Polyclinic (24x7): Non-functional as AAM-PHC:
24x7 PHC Non-functional as AAM: Other Primary Care Facility:
Ownership: Public
Reporting month: Financial Year:
Name & Designation of the person reported Data:
Date of reporting Data:
Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

Part A REPRODUCTIVE AND CHILD HEALTH

M1 Ante Natal Care (ANC) Services & High Risk Pregnancies
1.1. Total number of NEW Pregnant Women registered for ANC

1.1.a Out of total number of NEW pregnant women registered with age less than <15 years

1.1.b Out of total number of NEW pregnant women registered with age 15-19 years

Out of total number of NEW pregnant women registered with age more than >19 to
1.1.c
49 years
Out of total number of NEW pregnant women registered with age more than >49
1.1.d
years
Out of the total NEW ANC registered, number registered within 1st trimester (within
1.1.1.
12 weeks)
1.1.2 Total ANC footfall/cases (Old cases + New Registration) attended

1.2. ANC services

1.2.1. Number of PW given Td1 (Tetanus Diptheria dose 1)

1.2.2. Number of PW given Td2 (Tetanus Diptheria dose 2)

1.2.3. Number of PW given Td Booster (Tetanus Diptheria dose booster)

1.2.4. Number of PW provided full course 180 Iron Folic Acid (IFA) tablets

1.2.5. Number of PW provided full course 360 Calcium tablets

1.2.6. Number of PW given one Albendazole tablet after 1st trimester

1.2.7. Number of PW received 4 or more ANC check ups

1.2.8. Number of PW given ANC Corticosteroids in Pre-Term Labour

1.3. Pregnant Women (PW) with Hypertension (BP>140/90)

1.3.1. New cases of PW with hypertension detected

1.3.2. Number of PW with hypertension managed at institution

Page 1 of 21
 Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)
1.3.3. Number of New Pre-Eclampsia/Eclampsia cases identified
1.3.4. Number of Pre-Eclampsia/Eclampsia cases managed during ANC
1.3.5. Number of Eclampsia cases managed during delivery

1.4. Pregnant Women (PW) with Anaemia

Number of PW tested for Haemoglobin (Hb ) 4 or more than 4 times for respective
1.4.1.
ANCs
1.4.2. Number of PW tested for Haemoglobin (Hb)
1.4.3. Number of PW having Hb level<11(7.1 to 10.9 g/dl) (Out of total tested cases)

1.4.4. Number of PW having Hb level<=7 g/dl (Out of total tested cases)

1.4.5. Number of PW treated for severe anaemia (Hb<=7g/dl) (including referred-in cases)

1.5. Pregnant Women (PW) with Gestational Diabetes Mellitus (GDM)

1.5.1. Number of PW tested for Blood Sugar using OGTT(Oral Glucose Tolerance Test)

Number of PW tested positive for GDM out of total OGTT(Oral Glucose Tolerance
1.5.2.
Test) conducted
Number of GDM positive PW managed with Insulin/Metformin out of total tested
1.5.3.
positive for GDM
1.6. Pregnant Women (PW) with Syphilis

1.6.1 Syphilis test conducted for Pregnant Women

Number of pregnant/Direct-In-Labor (DIL) women screened/tested (with
1.6.1.a
VDRL/RPR/TPHA/RDT/PoC) for Syphilis
Number of pregnant/DIL women found seropositive for Syphilis by
1.6.1.b
VDRL/RPR/TPHA/RDT/PoC test
Number of pregnant/DIL women found Syphilis-Seropositive and given treatment
1.6.1.c
with injection Benzathine Penicillin (IM)
1.6.1.d Number of live births among Syphilis seropositive Pregnant Women
Number of babies born to Syphilis-Seropositive Pregnant Women tested positive/
1.6.1.e
clinically diagnosed for congenital Syphilis
1.6.1.f Out of above, babies with congenital Syphilis received curative treatment
1.7. Thyroid test conducted for Pregnant Women
1.7.1. Number of Pregnant Women tested positive for Thyroid disorder

1.7.2. Number of Pregnant Women treated for thyroid disorder

1.8. Tuberculosis test conducted for Pregnant Women

1.8.1. Number of Pregnant Women screened for TB

1.8.2. Number of Pregnant Women identified with Presumptive TB symptoms

Number of Pregnant Women referred out of those identified with Presumptive TB
1.8.3.
symptoms
1.9. High Risk /Complicated Pregnancies

1.9.1. Total High Risk Pregnancy (HRP) Intrapartum including following:

Page 2 of 21
 Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)
Number of Pregnant Women only with Post-Partum Haemorrhage (Immediately after
1.9.1.a.
delivery) in the facility
1.9.1.b. Number of Pregnant Women only with Sepsis in the facility
1.9.1.c. Number of Pregnant Women identified only with Eclampsia in the facility

1.9.1.d. Number of Pregnant Women identified only with obstructed labour in the facility

1.9.1.e. Number of Pregnant Women identified with more than 1 complication listed above

1.9.2. Total High Risk Pregnancy (HRP) Antepartum (Only New Cases are to be reported)

1.9.3. Total no. of highrisk ANC cases referred to Higher/ any other facility (Referred out)

Total no. of Intrapartum/PNC High Risk Pregnancy cases referred to Higher/ any
1.9.3.a
other facility (Referred out)
1.9.4 Total no. of highrisk ANC cases referred in to the facility (Referred in)
Total no. of Intrapartum/PNC High Risk Pregnancy cases attended or referred into
1.9.4.a
the facility (Referred in)
M2 Deliveries
2.1. Deliveries conducted at Home

2.1.1. Number of Home Deliveries attended by

Number of Home Deliveries attended by Skill Birth Attendant(SBA)
2.1.1.a
(Doctor/Nurse/ANM)
2.1.1.b Number of Home Deliveries attended by Non SBA

2.1.2. Number of PW given Tablet Misoprostol during home delivery

2.2. Number of Institutional Deliveries conducted (Including C-Sections)

Out of total institutional deliveries(excluding C-section), number of women stayed
2.2.1.
for 48 hours or more after delivery
Out of total Institutional deliveries, number of Institutional Deliveries (Excluding C-
2.2.2
Sections) conducted at night (8 PM- 8 AM)
Age wise total number of delivery (Home +Institutional) reported
2.3.
(2.3.1+2.3.2+2.3.3+2.3.4)
2.3.1. Out of total number of delivery, PW with age less than <15 years

2.3.2. Out of total number of delivery, PW with age 15-19 years

2.3.3. Out of total number of delivery, PW with age more than >19-49 years

2.3.4. Out of total number of delivery, PW with age more than > 49 years

2.4. Number of newborns received 6/7 HBNC visits after Delivery (Home+ Institutional)

2.5. No. of identified Sick new-borns referred by ASHA to facility under HBNC Programme

2.6. Total number of Children received all scheduled 5 Home visits under HBYC

M3 Number of Caesarean (C-Section) deliveries

3.1. Total number of C -Section deliveries performed

Page 3 of 21
 Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

Page 4 of 21
3.1.1. Out of total C-sections, number performed at night (8 PM- 8 AM)

3.1.2. Out of total C-section, number of women stayed for 72 hours or more after delivery

M4 Pregnancy outcome & details of new-born/children

4.1. Pregnancy Outcome (in number)
4.1.1. Live Birth
4.1.1.a Live Birth - Male

4.1.1.b Live Birth - Female

4.1.2. Number of Pre-term newborns ( < 37 weeks of pregnancy)

4.1.3. Still Birth

4.1.3.a Intrapartum (Fresh) Still Birth

4.1.3.b Antepartum (Macerated) Still Birth

4.2. Abortion (spontaneous)

4.3. Medical Termination of Pregnancy (MTP)

4.3.1. Number of MTPs conducted

4.3.1.a Surgical MTPs upto 12 weeks of pregnancy

4.3.1.b MTP more than 12 weeks of pregnancy

4.3.1.c MTPs completed through Medical methods of abortion (MMA)

4.3.2. Post-abortion/MTP Complications

4.3.2.a Total Post-abortion/MTP Complications Identified

Post-abortion/MTP complications identified (where abortions were carried out in
4.3.2.b.
facilities other than public and accredited private health facilities)
4.3.2.c. Post-abortion/MTP Complications treated

4.3.3. Number of women provided with Post-abortion/ MTP contraception

4.4. Details of Newborn children

4.4.1. Number of Newborns weighed at birth

4.4.2. Number of Newborns having weight less than 2500 gms

4.4.2.a Out of the above, number of Newborns having weight less than 1800 gms

4.4.3. Number of Newborns breast fed within 1 hour of birth

4.4.4. No. of Newborns discharged from the facility were exclusively breastfed till discharge

4.5. Rashtriya Bal Swasthya Karyakram (RBSK)

Number of Newborns screened for defects at birth (as per Comprehensive Newborn
4.5.1
Screening, RBSK)
Number of Newborns identified with visible birth defects (including Neural tube
4.5.1.a defect, Down’s Syndrome, Cleft Lip & Palate, Club foot and Developmental dysplasia
of the hip)

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

Number of children till age 18 years (affected with selected health conditions)
4.5.2
managed for 4 Ds (Disease, Deficiency, Developmental Delay & Defect)
Page 5 of 21
M5 Anaemia Mukt Bharat
5.1. IFA Coverage
Number of women of reproductive age (WRA) 20-49 years (non-pregnant, non-
5.1.1.
lactating), provided 4 Red Iron and folic acid (IFA) tablets in a month
Number of children (6-59 months old) provided 8-10 doses (1ml) of IFA syrup (Bi
5.1.2.
weekly)
Number of children 5-9 years provided Weekly Iron Folic Acid (IFA Pink) tablets in a
5.1.3.
month
Number of out of school children (5 -9 years) given 4-5 IFA Pink tablets at Anganwadi
5.1.3.a
Centres
5.2. Anaemia- Identified & Treated
5.2.1. Beneficiaries identified with Mild and Moderate Anaemia
Number of out of school adolescent girls (10-19 years) having anaemia (Hb 8.1-11.9
5.2.1.a
g/dl)
Number of lactating mothers (of 0-6 months old child) having anaemia (Hb 8.1-11.9
5.2.1.b
g/dl)
Number of women of reproductive age (non-pregnant, non-lactating) (20-49 years)
5.2.1.c
having anaemia (Hb 8.1-11.9 g/dl)
5.2.2. Beneficiaries identified with Severe Anaemia
Number of out of school adolescent girls (10-19 years) having severe anaemia (Hb <8
5.2.2.a
g/dl)
Number of lactating mothers (of 0-6 months old child) having severe anaemia (Hb <8
5.2.2.b
g/dl)
Number of women of reproductive age (non-pregnant, non-lactating) (20-49 years)
5.2.2.c
having severe anaemia (Hb <8 g/dl)
5.2.3. Beneficiaries diagnosed with mild and moderate Anaemia, put on treatment

5.2.3.a Number of anaemic in-school Children (5-9 years) put on treatment

5.2.3.b Number of anaemic in-school adolescent girls (10-19 years) put on treatment

5.2.3.c Number of anaemic out of school adolescent girls (10-19 years) put on treatment

5.2.3.d Number of anaemic in-school adolescent boys (10-19 years) put on treatment

5.2.3.e Number of anaemic lactating mothers (of 0-6 months old child) put on treatment

Number of anaemic women of reproductive age (non-pregnant, non-lactating) (20-49

5.2.3.f
years) put on treatment
M6 Post Natal Care (PNC)
In case of home delivery, number of women receiving 1st Postpartum checkups
6.1.
within 48 hours
Number of women receiving Postpartum checkup between 48 hours and 14 days
6.2.
after Institutional delivery
6.3. Number of mothers provided full course of 180 IFA tablets after delivery

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

6.4. Number of mothers provided full course 360 Calcium tablets after delivery

6.5. Total No of High Risk Mothers identified during Post Natal Period
Out of above identified number of High Risk Mothers managed (including referred in
6.6.
cases)
Page 6 of 21
 Sexually Transmitted Infections/Reproductive Tract Infections
M7
(STI/RTI) Cases
7.1. Number of new STI/RTI cases identified

7.1.1. Number of males assessed for STI/RTI

7.1.1.a Out of the above, number of males diagnosed with STI/RTI

7.1.1.b Out of the above, number of males treated for STI/RTI

7.1.2. Number of females (all females) assessed for STI/RTI

7.1.2.a Out of the above, number of females (all females) diagnosed with STI/RTI

7.1.2.b Out of the above, number of females (all females) treated for STI/RTI

7.1.3. Number of H/TG assessed for STI/RTI

7.1.3.a Out of the above, number of H/TG people diagnosed with STI/RTI

7.1.3.b Out of the above, number of H/TG people treated for STI/RTI

M8 Family Planning
8.1. MALE STERILIZATION

8.1.1. Number of Non Scalpel Vasectomy (NSV) / Conventional Vasectomy conducted

8.2. FEMALE STERILIZATION

8.2.1. Number of Laparoscopic sterilizations (excluding post-abortion) conducted

Number of Interval sterilizations (Mini-lap/Conventional) (other than postpartum and
8.2.2.
Post-abortion) conducted
Number of Postpartum sterilizations (within 7 days of delivery by minilap or
8.2.3.
concurrent with caesarean section) conducted
Number of Post-abortion sterilizations (within 7 days of Spontaneous or surgical
8.2.4.
abortion) conducted
8.3. Number of Interval IUCD Insertions (excluding PPIUCD and PAIUCD)

8.4. Number of Postpartum (within 48 hours of delivery) IUCD insertions

Number of Post-abortion (within 12 days of Spontaneous or surgical abortion) IUCD
8.5.
insertions
8.6. Number of IUCD Removals

8.7. Number of complications following IUCD Insertion

8.8. Injectable Contraceptive MPA- First Dose

8.8.1. Injectable Contraceptive MPA (Intra Muscular) - First Dose

8.8.2. Injectable Contraceptive MPA (Sub Cutaneous) - First Dose

8.9. Injectable Contraceptive MPA- Second Dose

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

8.9.1. Injectable Contraceptive MPA (Intra Muscular) - Second Dose

8.9.2. Injectable Contraceptive MPA (Sub Cutaneous)- Second Dose

8.10. Injectable Contraceptive MPA- Third Dose

8.10.1. Injectable Contraceptive MPA (Intra Muscular) - Third Dose

8.10.2. Injectable Contraceptive MPA (Sub Cutaneous)- Third Dose

Page 7 of 21
8.11. Injectable Contraceptive MPA- Fourth and above Dose

8.11.1. Injectable Contraceptive MPA (Intra Muscular) - Fourth and above Dose

8.11.2. Injectable Contraceptive MPA (Sub Cutaneous)- Fourth and above Dose

8.12. Number of Combined Oral Pill cycles distributed to the beneficiary

8.13. Number of Condom pieces distributed to the beneficiary

8.14. Number of Centchroman (weekly) pill strips distributed to the beneficiary

8.15. Number of Emergency Contraceptive Pills (ECP) given to the beneficiary

8.16. Number of Pregnancy Test Kits (PTK) utilized

8.17. No. of Subdermal Contraceptive Implant

8.17.1 No. of Subdermal Contraceptive Implant inserted

8.17.2 No. of Subdermal Contraceptive Implant removed

8.18. Quality in sterilization services

8.18.1 Complications following male sterilization

8.18.2 Complications following female sterilization

8.18.3 Failures following male sterilization

8.18.4 Failures following female sterilization

8.18.5 Deaths following male sterilization

8.18.6 Deaths following female sterilization

8.19. Follow up in Sterilization
Number of cases of Female Sterilization followed up (after 1 month or on the
8.19.1
resumption of her menstrual cycle whichever is earlier)
8.19.2 Number of cases of Male Sterilization followed up (after 3 months)
M9 CHILD IMMUNISATION
9.1. Number of Infants 0 to 11 months old who received:
9.1.1. Child immunisation - Vitamin K (Birth Dose)
9.1.2. Child immunisation - BCG
9.1.3. Child immunisation - Pentavalent 1
9.1.4. Child immunisation - Pentavalent 2
9.1.5. Child immunisation - Pentavalent 3

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

9.1.6. Child immunisation - OPV 0 (Birth Dose)

9.1.7. Child immunisation - OPV1
9.1.8. Child immunisation - OPV2
9.1.9. Child immunisation - OPV3
9.1.10. Child immunisation - Hepatitis-B0 (Birth Dose)
9.1.11. Child immunisation - Inactivated Injectable Polio Vaccine 1 (IPV 1)
9.1.12. Child immunisation - Inactivated Injectable Polio Vaccine 2 (IPV 2)

Page 8 of 21
9.1.13. Child immunisation - Rotavirus 1
9.1.14. Child immunisation - Rotavirus 2
9.1.15. Child immunisation - Rotavirus 3
9.1.16. Child immunisation - PCV1
9.1.17. Child immunisation - PCV2
9.2. Number of Children 9-11 months who received:

9.2.1. Child immunisation(9 - 11 months) - Inactivated Injectable Polio Vaccine 3 (IPV 3)

Child immunisation (9-11months) - Measles & Rubella (MR)/Measles containing
9.2.2.
vaccine(MCV) - 1st Dose
9.2.3. Child immunisation (9-11months) - JE 1st dose
9.2.4. Child immunisation - PCV Booster

Number of children aged between 9 and <12 months FULLY IMMUNIZED {BCG
9.2.5.
+OPV123+ Pentavalent123+ MR/ Measles Containing Vaccine (MCV)-1st Dose}

9.2.5.a FULLY IMMUNIZED children aged between 9 and <12 months- Male

9.2.5.b FULLY IMMUNIZED children aged between 9 and <12 months- Female

9.3. Children given following vaccination after 12 months (delayed vaccinations)

Child immunisation(after 12 months-delayed vaccination) - Measles & Rubella
9.3.1.
(MR)/Measles containing vaccine(MCV)- 1st Dose
9.3.2. Child immunisation (after 12 months-delayed vaccination) - JE 1st dose

9.3.3. Child immunisation - DPT 1 after 12 months of age (delayed vaccination)

9.3.4. Child immunisation - DPT 2 after 12 months of age (delayed vaccination)

9.3.5. Child immunisation - DPT 3 after 12 months of age (delayed vaccination)

9.3.6. Child immunisation - DPT Booster after 24 months of age (delayed vaccination)

9.3.7. Child immunisation - OPV Booster after 24 months of age (delayed vaccination)

9.3.8. Child immunisation - JE Booster after 24 months of age (delayed vaccination)

9.4. Number of Children more than 12 months who received:

Child immunisation - Measles & Rubella (MR)/ Measles containing vaccine(MCV)- 2nd
9.4.1.
Dose (16-24 months)

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

9.4.2. Child immunisation - DPT 1st Booster

9.4.3. Child immunisation - OPV Booster

Number of children more than 16 months of age who received Japanese Encephalitis
9.4.4.
(JE) vaccine- 2nd dose (16-24 months)
9.5. Number of Children more than 23 months who received:

9.5.1. Child Immunization- Typhoid

9.5.2. Children more than 5 years received DPT5 (2nd Booster)

9.5.3. Children more than 10 years received Td10 (Tetanus Diptheria10)

9.5.4. Children more than 16 years received Td16 (Tetanus Diptheria16)

Page 9 of 21
9.6. Adverse Event Following Immunisation (AEFI)

9.6.1. Number of cases of AEFI -Minor (eg.- fever, rash, pain etc)
Number of cases of AEFI - Severe (eg.- anaphylaxis, fever>102 degrees, not requiring
9.6.2.
hospitalization etc.)
9.6.3. Number of cases of AEFI - Serious (eg.- hospitalization, death, disability , cluster etc.)

9.6.3.a Out of Number of cases of AEFI - Serious , total number of AEFI deaths

9.7. Number of Immunisation sessions

9.7.1. Immunisation sessions planned

9.7.2. Immunisation sessions held

9.8. Children received Vitamin A Doses between 9 months and 5 years

9.8.1. Child immunisation - Vitamin A Dose - 1

9.8.2. Child immunisation - Vitamin A Dose - 5

9.8.3. Child immunisation - Vitamin A Dose - 9

M10 Number of cases of Childhood Diseases

New Cases of Childhood Diseases (0-5 years) & Leprosy (0-14 years)
10.1.
Include new cases of OPD/IPD/Emergency
10.1.1. Childhood Diseases - Pneumonia

10.1.2. Childhood Diseases - Asthma

10.1.3. Childhood Diseases - Sepsis

10.1.4. Childhood Diseases - Diphtheria

10.1.5. Childhood Diseases - Pertussis

10.1.6. Childhood Diseases - Tetanus Neonatorum

10.1.7. Childhood Diseases - Tuberculosis (TB)

10.1.8. Childhood Diseases - Acute Flaccid Paralysis(AFP)

10.1.9. Childhood Diseases - Measles

10.1.10. Childhood Diseases - Malaria

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

10.1.11. Childhood Diseases - Diarrhoea

10.1.12. Childhood Diseases - Diarrhoea treated with ORS

10.1.13. Childhood Diseases - Diarrhoea treated with Zinc for 14 days

10.1.14. Childhood Diseases -Leprosy Cases

10.1.15. Childhood Diseases- Leprosy with Grade II disability

10.2. Childhood IPD

10.2.1. Children admitted with Respiratory Infections

10.2.2. Children admitted with Pneumonia

10.2.3. Children admitted with Diarrhoea

Part B National Programmes

Page 10 of 21
M11 National Vector Borne Disease Control Programme (NVBDCP)
11.1. Malaria

11.1.1. Microscopy Tests

11.1.1.a Total Blood Smears Examined for Malaria

11.1.1.b Malaria (Microscopy Tests ) - Plasmodium Vivax test positive

11.1.1.c Malaria (Microscopy Tests ) - Plasmodium Falciparum test positive

11.1.1.d Malaria (Microscopy Tests ) - Mixed test positive

11.1.2. Rapid Diagnostic Test (RDT )

11.1.2.a RDT conducted for Malaria

11.1.2.b Malaria (RDT) - Plasmodium Vivax test positive

11.1.2.c Malaria (RDT) - Plasmodium Falciparum test positive

11.1.2.d Malaria (RDT) - Mixed test positive

11.2. Kala Azar- Rapid Diagnostic Test (RDT)

11.2.1. Kala Azar (RDT) - Tests Conducted

11.2.2. Kala Azar Positive Cases

11.3. Lymphatic Filariasis

Number of persons that consumed MDA (Mass Drug Administration) drugs during
11.3.1.
the MDA round
Number of Lymphatic Filarisis lymphoedema patients received MMDP(Morbidity
11.3.2.
Management And Disability Prevention) kits
M12 Adolescent Health
12.1. Adolescent Friendly Health Clinics (AFHCs)
Number of Adolescents (10-19 years) registered in Adolescent Friendly Health Clinic
12.1.1
(AFHC)
12.1.1.a Girls registered in AFHC

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

12.1.1.b Boys registered in AFHC

12.1.2. Out of registered adolescents (10-19 years), number received clinical services

12.1.2.a Out of Girls registered, Girls received clinical services

12.1.2.b Out of Boys registered, Boys received clinical services

12.1.3. Out of registered adolescents (10-19 years), number received counselling

12.1.3.a Out of Girls registered, Girls received counselling

12.1.3.b Out of Boys registered, Boys received counselling

12.2. Coverage under MHS- Menstrual Hygiene Scheme (GOI supported)

12.2.1. Number of adolescent girls provided sanitary napkin packs by ASHA

12.2.2. Number of sanitary napkin packs distributed free to ASHA (for her personal use)

12.2.3. Number of adolescent girls attended monthly meeting

Page 11 of 21
 Number of adolescent girls provided sanitary napkin packs by State/UT supported
12.2.4.
Menstrual Hygiene Scheme (MHS)
12.3. Peer Educator Programme
12.3.1. Number of Peer Educators selected

12.3.2. Out of the selected Peer Educators, numbers trained

12.3.3. Number of Adolescent Health & Wellness Days organized

12.3.4. Number of Adolescent Friendly Club Meetings organized

Part C Health Facility Services

M13 Patient Services
13.1. Services provided

13.1.1. Geriatric/Elderly

13.1.1.a Total number of geriatric/elderly patients (age>=60 yrs) Registered

13.1.1.b Geriatric (age>=60 yrs) patients footfall

Number of geriatric/elderly persons who underwent Comprehensive Geriatric
13.1.1.c
Assessment by CHO
13.1.1.d Number of geriatric/elderly persons managed for any elderly conditions

13.1.1.e Number of geriatric/elderly persons followed-up for any elderly conditions

13.1.1.f Number of geriatric/elderly patients (age>=60 yrs) provided physiotherapy services

Number of home bound (bed bound & restricted mobility) elderly and single elderly
13.1.1.g
visited by ASHA & ANM/MPW-M during the month
13.1.1.h Number of elderly support groups-‘Sanjeevini’ created during the month

13.1.1.i Number of weekly geriatric clinics organized during the month

13.1.1.j Number of fixed day rehabilitation services provided during the month

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

13.1.2. Other Services

13.1.2.a Number of patients provided physiotherapy services

13.1.2.b Number of Palliative Patients visited at home

13.1.2.c Number of visits for home care/ end of life care provided by AAM-PHC team

13.1.2.d Number of weekly palliative care OPD conducted at AAM-PHC

13.1.2.e Number of cases reported for Self Harm

13.1.3. Services provided in outreach camps during the month

13.1.3.a Total number of footfall in outreach camps/sessions

13.1.3.b Total number cases examined in outreach camps for Mental illness
Number of psychoeducation sessions conducted at the Ayushman Arogya Mandir
13.1.3.c
during the month
13.2. Outpatient attendance (All) (excluding teleconsultation)

13.2.1. Allopathic- Outpatient attendance

13.2.1.a Out of above, number of specialist Allopathic OPD services provided

Page 12 of 21
13.2.2. Ayush - Outpatient attendance

13.2.2.a Out of above, number of specialist AYUSH OPD services provided

13.3. Inpatient details
13.3.1. IPD Admission
13.3.1.a IPD Admission Male- Children<18yrs

13.3.1.b IPD Admission Male- Adults <60yrs

13.3.1.c IPD Admission Female- Children<18yrs

13.3.1.d IPD Admission Female- Adults<60yrs

13.3.1.e IPD Admission Geriatric->=60yrs

13.3.2. IPD Discharge
13.3.2.a IPD Discharge Male- Children<18yrs

13.3.2.b IPD Discharge Male- Adults<60yrs

13.3.2.c IPD Discharge Female- Children<18yrs

13.3.2.d IPD Discharge Female- Adults<60yrs

13.3.2.e IPD Discharge Geriatric->=60yrs

13.3.3. IPD Referred Out
13.3.3.a IPD Referred Male- Children<18yrs

13.3.3.b IPD Referred Male- Adults<60yrs

13.3.3.c IPD Referred Female- Children<18yrs

13.3.3.d IPD Referred Female- Adults<60yrs

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

13.3.3.e IPD Referred Geriatric->=60yrs

IPD Deaths (excluding deaths at Emergency department & Sick Newborn Care Unit
13.3.4.
(SNCU)
13.3.4.a IPD Deaths Male- Children<18yrs
13.3.4.b IPD Deaths Male- Adults<60yrs
13.3.4.c IPD Deaths Female- Children<18yrs
13.3.4.d IPD Deaths Female- Adults<60yrs
13.3.4.e IPD Deaths Geriatric->=60yrs
13.3.5. Total Number of cases Referred out (OPD+IPD+Emergency)
13.3.5.a Total cases Referred out (OPD+IPD+Emergency)-During Day
13.3.5.b Total cases Referred out (OPD+IPD+Emergency)-At Night (8 PM- 8 AM)
13.3.6. Day Care Admissions
13.3.7. Number of Left Against Medical Advice (LAMA) cases

13.3.7.a Number of Total Left Against Medical Advice (LAMA) cases reported at the facility

13.3.7.b Number of delivery LAMA cases reported at the facility

13.3.8. Total number of Medico Legal Cases reported at the facility

Page 13 of 21
13.3.9. Total number of telemedicine consultation provided

13.4. Inpatient by disease/ health condition

13.4.1. Inpatient - Malaria

13.4.2. Inpatient - Dengue

13.4.3. Inpatient - Typhoid

Inpatient - Asthma, Chronic Obstructive Pulmonary Disease (COPD), Respiratory
13.4.4.
infections
13.4.5. Inpatient - Tuberculosis

13.4.6. Inpatient - Pyrexia of unknown origin (PUO)

13.4.7. Inpatient - Diarrhoea with dehydration

13.4.8. Inpatient – Palliative Care

13.5. Emergency

13.5.1. Patients registered at Emergency Department

13.5.2. No. of Emergencies managed at night (8 PM- 8 AM)

13.5.3. Total Number of Emergency cases managed

13.5.4. Total Number of Emergency cases referred out

13.5.5. Total Number of CPR performed in the emergency

13.6. Emergency admissions/deaths due to

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

13.6.1.a Emergency - Trauma ( accident, injury, poisoning etc) -Admission

13.6.1.b Emergency - Trauma ( accident, injury, poisoning etc) -Deaths

13.6.2.a Emergency - Burn -Admission

13.6.2.b Emergency - Burn -Deaths

13.6.3.a Emergency - Obstetrics complications -Admission

13.6.3.b Emergency - Obstetrics complications -Deaths

13.6.4.a Emergency - Snake Bite -Admission

13.6.4.b Emergency - Snake Bite -Deaths

13.6.5.a Emergency - Acute Cardiac Emergencies -Admission

13.6.5.b Emergency - Acute Cardiac Emergencies -Deaths

13.6.6.a Emergency - CVA (Cerebrovascular Disease)/Stroke -Admission

13.6.6.b Emergency - CVA (Cerebrovascular Disease)/Stroke -Deaths

13.6.7.a Emergency - Dog Bite -Admission

13.6.7.b Emergency - Dog Bite -Deaths

13.7. Total number of deaths occurring at Emergency Department

13.8. Minor Operations (No or local anaesthesia)

Page 14 of 21
13.9. In-Patient Head Count at midnight

13.10. Sick Newborns (up to 4 weeks) Admissions

13.10.1. Number of Admission in NBSU ( New Born Stabilisation Unit)

13.11. Janani Shishu Suraksha Karyakram (JSSK)

13.11.1. Number of Pregnant Women(PW) and Post Natal Care (PNC) Beneficiaries
13.11.1.a Number of PW and PNC beneficiaries provided - Free Medicines under JSSK

13.11.1.a.i Number of pregnant women provided free medicines during ANC period under JSSK

13.11.1.a.ii Number of Pregnant women provided free medicines during delivery under JSSK

13.11.1.a.iii Number of PNC mothers provided free medicines under JSSK

13.11.1.b Number of women provided - Free Diet under JSSK

13.11.1.c Number of PW and PNC beneficiaries provided - Free Diagnostics under JSSK

13.11.1.c.i Number of pregnant women provided free diagnostics during ANC period under JSSK

13.11.1.c.ii Number of Pregnant women provided free diagnostics during delivery under JSSK

13.11.1.c.iii Number of PNC mothers provided free diagnostics under JSSK

Number of pregnant women provided - Free Home to facility transport for
13.11.1.d
conducting delivery under JSSK

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)
Number of pregnant women provided - Interfacility transfers when needed during
13.11.1.e
delivery under JSSK(in case of referral)
13.11.1.f Number of PNC mothers provided - Free Drop Back home after delivery under JSSK

13.11.2. Number of sick infants provided

13.11.2.a Number of infants admitted at facility due to any sickness- JSSK Beneficiaries

13.11.2.b Number of sick infants provided - Free Medicines under JSSK

13.11.2.c Number of sick infants provided - Free Diagnostics under JSSK

13.11.2.d Number of sick infants provided - Free Home to facility transport under JSSK

13.11.2.e Number of infants received free referral transport under JSSK

13.12. Nutritional Rehabilitation Centre (NRC)

13.12.1. Number of sick SAM children admitted in standalone/ integrated NRC

Number of sick SAM children referred to standalone/ integrated NRC by Frontline
13.12.2.
Workers (AWW/ ASHA/ ANM)
Number of sick SAM children referred to standalone/ integrated NRC from IPD/OPD
13.12.3.
of other Health Facility (PHC/CHC/SDH/DH/other NRC)
13.12.4. Number of children Referred to standalone/ integrated NRC by RBSK Team
Number of SAM children discharged from standalone/ integrated NRC who met the
13.12.5.
discharge criteria
13.12.6. Number of admitted children left against medical advice (LAMA) / defaulter

13.12.7. Number of children died while admitted in standalone/ intergrated NRC

Page 15 of 21
13.12.8. Number of children who completed all four post discharge follow-ups
Number of sick SAM children treated and admitted in the pediatric facility (other
13.12.9.
than standalone/ integrated NRC)
13.12.10. In-Patient Head Count at midnight for standalone/ integrated NRC

13.13.1. Number of Rogi Kalyan Samiti (RKS) meetings held

13.13.2. Number of Jan Arogya Samiti (JAS) meetings held

Number of Anganwadi centres reported to have conducted atleast one Village Health
13.14.
& Nutrition Day (VHNDs)/UHND/ Outreach / Special Outreach sessions

13.15. Total number of UHND/VHND sessions conducted in the reporting month

Total number of Outreach/Special Outreach camps conducted in the reporting
13.16.
month
13.16.1. Total number of outreach visits conducted by staff

13.17. Patient Satisfaction Score of the facility in percentage (from Mera Aspatal)
National Viral Hepatitis Control Program (Diagnosis and Management of viral
13.18.
hepatitis)
13.18.1. Total number of blood samples screened by ELISA/Rapid tests for viral hepatitis
Total number of blood samples screened by ELISA/Rapid tests for viral hepatitis B i.e.
13.18.1.a
HBsAg (excluding pregnant women)
Total number of blood samples screened by ELISA/Rapid tests for viral hepatitis
13.18.1.b
C(Anti- HCV)

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)
Total number of blood samples tested positive by ELISA/ Rapid tests for viral
13.18.2.
hepatitis & its management
Total number of blood samples tested positive by ELISA/ Rapid tests for Hepatitis B
13.18.2.a
(out of those tested for HBsAg excluding pregnant women)
Total number of positive blood samples for hepatitis B by ELISA/ Rapid tests tested
13.18.2.a.i
for HBV DNA(out of those tested positive for HBsAg excluding pregnant women)

Total number of patients found positive for HBsAg eligible for treatment for hepatitis
13.18.2.a.ii
B (excluding pregnant women)
Total number of patients eligible for treatment for Hepatitis B put on treatment(out
13.18.2.a.iii
of those eligible for treatment excluding pregnant women)
Total number of blood samples tested positive by ELISA/ Rapid tests for Hepatitis C
13.18.2.b
(out of those tested for Anti-HCV)
Total number of positive blood samples for Hepatitis C screened by test (ELISA/ Rapid
13.18.2.b.i
tests) confirmed by HCV RNA testing (out of those positive for anti-HCV)
Total number of patients put on treatment for Hepatitis C (out of those confirmed by
13.18.2.b.ii
HCV RNA i.e. HCV RNA detected)
13.18.2.b.iii Total number of positive Hepatitis C patients who have completed treatment
Total number of patients cleared for HCV RNA on sustained virological response at 12
13.18.2.b.iv
weeks (SVR12)
13.18.3. Hepatitis B in pregnancy

13.18.3.a Number of Pregnant Women tested for HBsAg

Number of Pregnant Women who are HBsAg positive(out of those tested for
13.18.3.b
Hepatitis B i.e. HBsAg)
Number of Pregnant Women found positive for HBsAg referred out to higher centre
13.18.3.c
for institutional delivery

Page 16 of 21
13.18.3.d Number of Pregnant Women found positive for HBsAg delivered in an institution
Number of newborn who received birth dose of Hepatitis B vaccine born to HBsAg
13.18.3.e
positive pregnant women
Number of New Borns to Pregnant Women (found positive for HBsAg) received
13.18.3.f
Hepatitis B Immunoglobulin (HBIG) (within 24 hours of birth)
M14 Diagnostics
14.1. Total Number of Lab Tests & Kit Tests
Total Number of Lab Tests done- Inhouse (including kits tests conducted in
14.1.1.
Laboratory)
Total Number of Lab Tests done- Outsourced (including kits tests conducted in
14.1.2.
Laboratory)

14.1.3. Total Number of Kit Tests conducted in Outreach areas/Camps/in-facility(outside lab)

14.2. Hb Tests Conducted

14.2.1 Number of Hb tests conducted including kit tests

14.2.2 Out of the total number of Hb tests done, Number having Hb < 7 mg

14.3. HIV tests

14.3.1.a Number of males screened for HIV by Whole Blood Finger Prick/RDT test/POC test

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

14.3.1.b Out of the above, No. of males found reactive for HIV

14.3.1.c No. of males subjected to HIV test at Confirmatory Centre/Stand Alone-ICTC

14.3.1.d Out of the above, No. of males confirmed as HIV Positive

Number of females (non-ANC) screened for HIV by Whole Blood Finger Prick/RDT
14.3.2.a
test/POC test
14.3.2.b Out of the above, No. of females (non-ANC) found reactive for HIV
No. of females (non-ANC) subjected to HIV test at Confirmatory Centre/Stand Alone-
14.3.2.c
ICTC
14.3.2.d Out of the above, No. of females (non-ANC) confirmed as HIV Positive
Number of Pregnant Women (PW-ANC) screened for HIV by Whole Blood Finger
14.3.3.a
Prick/RDT test/POC test
14.3.3.b Out of the above, No. of PW(ANC) found reactive for HIV

14.3.3.c No. of PW(ANC) subjected to HIV test at Confirmatory Centre/Stand Alone-ICTC

14.3.3.d Out of the above, No. of PW(ANC) confirmed as HIV Positive

Number of DIL women screened for HIV by Whole Blood Finger Prick/RDT test/POC
14.3.3.e
test
14.3.3.f Out of the above, No. of DIL women found reactive for HIV
Number of Pregnant Women (ANC&DIL) screened for HIV more than once(Repeated
14.3.3.g
testing)
Number of H/TG people screened for HIV by Whole Blood Finger Prick/RDT test/POC
14.3.4.a
test
14.3.4.b Out of the above, No. of H/TG people found reactive for HIV

14.3.4.c No. of H/TG people subjected to HIV test at Confirmatory Centre/Stand Alone-ICTC

Page 17 of 21
14.3.4.d Out of the above, No. of H/TG people confirmed as HIV Positive

14.4. STI/RTI attendees Tested for Syphilis

14.4.1.a Total number of males tested for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)

Out of the above, number of males tested reactive for Syphilis (RPR/VDRL/PoC/
14.4.1.b
RDT/TPHA)
14.4.1.c Out of the above, number of males treated for Syphilis

14.4.2.a Total number of female (non-ANC) tested for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
Out of the above, number of females (non-ANC) tested reactive for Syphilis
14.4.2.b
(RPR/VDRL/PoC/ RDT/TPHA)
14.4.2.c Out of the above, number of females (non-ANC) treated for Syphilis

14.4.3.a Total number of H/TG people tested for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
Out of the above, number of H/TG people tested reactive for Syphilis
14.4.3.b
(RPR/VDRL/PoC/ RDT/TPHA)
14.4.3.c Out of the above, number of H/TG people treated for Syphilis

14.5. Widal tests

14.5.1. Widal tests- Number Tested

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

14.5.2. Widal tests- Number Positive

14.6. Diagnostics Tests conducted

14.6.1. Radiology

14.6.1.a.i X-ray(Inhouse)

14.6.1.a.ii X-ray(Outsource)

14.6.1.b.i Ultrasonography (USG) (Inhouse)

14.6.1.b.ii Ultrasonography (USG)(Outsource)

14.6.1.c.i ECG (Inhouse)

14.6.1.c.ii ECG (Outsource)

Part D. Mortality Details

M15 Details of deaths reported:
New born deaths within 24 hrs(1 to 23 Hrs 59 minutes) of birth at Facility/ Facility to
15.1.1.a
facility in transit
New born deaths within 24 hrs(1 to 23 Hrs 59 minutes) of birth in Community (at
15.1.1.b
home or home to facility transit)

15.1.2.a New born deaths within 1 week (1 to 7 days) at Facility/Facility to facility in transit

New born deaths within 1 week (1 to 7 days) At Community (at home or home to
15.1.2.b
facility transit)
15.1.3.a New born deaths within 8 to 28 days at Facility/Facility to facility in transit
New born deaths within 8 to 28 days At Community (at home or home to facility
15.1.3.b
transit)
Infant Deaths (>28 days to below 12 months) at Facility/Facility to facility in transit
15.1.4.a

Page 18 of 21
 Infant Deaths (>28 days to below 12 months) At Community (at home or home to
15.1.4.b
facility transit)
15.2. Neonatal Deaths up to 4 weeks (0 to 28 days) due to

15.2.1. Neonatal Deaths up to 4 weeks (0 to 28 days) due to Sepsis

15.2.2. Neonatal Deaths up to 4 weeks (0 to 28 days) due to Asphyxia

15.2.3. Neonatal Deaths up to 4 weeks (0 to 28 days) due to complications of Prematurity

15.2.4. Neonatal Deaths up to 4 weeks (0 to 28 days) due to Other causes

15.3. Infant Deaths Between more than 28 days and below 12 months due to

15.3.1. Number of Infant Deaths (>28 days - below 12 months) due to Pneumonia

15.3.2. Number of Infant Deaths (>28 days -below 12 months) due to Diarrhoea

15.3.3. Number of Infant Deaths (>28 days -below 12 months) due to Fever related

15.3.4. Number of Infant Deaths (>28 days -below 12 months) due to Measles

15.3.5. Number of Infant Deaths (>28 days -below 12 months) due to Others

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

15.4. Child Deaths between 1 - below 5 years due to

15.4.1. Number of Child Deaths (1 -below 5 years) due to Pneumonia

15.4.2. Number of Child Deaths (1 -below 5 years) due to Diarrhoea

15.4.3. Number of Child Deaths (1 -below 5 years) due to Fever related

15.4.4. Number of Child Deaths (1 -below 5 years) due to Measles

15.4.5. Number of Child Deaths (1 -below 5 years) due to Others

15.5. Maternal Deaths at facility due to

Number of Maternal Deaths at facility due to APH (Antepartum Haemmorhage)
15.5.1.
Number of Maternal Deaths at facility due to PPH (Post-Partum Haemmorhage)
15.5.2.

Number of Maternal Deaths at facility due to Pregnancy related infection and sepsis,
15.5.3.
Fever
Number of Maternal Deaths at facility due to Abortion and/ or its complication
15.5.4.
Number of Maternal Deaths at facility due to Obstructed/prolonged labour
15.5.5.
Number of Maternal Deaths at facility due to Severe hypertension/fits/Pre
15.5.6.
Eclampsia/Eclampsia & in pregnancy, during delivery and puerperium
15.5.7. Number of Maternal Deaths at facility due to Other/Unknown Causes

15.5.8. Age wise total Maternal Deaths, occurred at Facility

Out of total number of maternal deaths at facility, deaths with age less than <15
15.5.8.a
years

15.5.8.b Out of total number of maternal deaths at facility, deaths with age 15-19 years

Out of total number maternal deaths at facility, deaths with age more than >19-49
15.5.8.c
years

Page 19 of 21
15.5.8.d Out of total number maternal deaths at facility, deaths with age more than >49 years

Other Deaths (except Infant, Child & Maternal Deaths) 5 years and above due
15.6.
to
15.6.1. Number of deaths due to Diarrhoeal diseases

15.6.2. Number of deaths due to Tuberculosis

15.6.3. Number of deaths due to Respiratory diseases including infections (other than TB)

15.6.4. Number of deaths due to Other Fever Related

15.6.5. Number of deaths due to Heart disease/Hypertension related

15.6.6. Number of deaths due to Cancer

15.6.7. Number of deaths due to Neurological disease including strokes

15.6.8. Number of deaths due to Accidents/Burn cases

15.6.9. Number of deaths due to Animal bites and stings

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

15.6.10. Number of deaths due to Known Acute Disease

15.6.11. Number of deaths due to Known Chronic Disease

15.6.12. Number of deaths due to Other Causes

15.7. Deaths due to Vector Borne Diseases ( all age groups)

15.7.1. Number of Deaths due to Malaria- Plasmodium Vivax

15.7.2. Number of Deaths due to Malaria- Plasmodium Falciparum

15.7.3. Number of Deaths due to Kala Azar

15.7.4. Number of Deaths due to Dengue

15.7.5. Number of Deaths due to Acute Encephelitis Syndrome (AES)

15.7.6. Number of Deaths due to Japanese Encephalitis (JE)

Total Deaths (5 years and above of age): Excluding in-transit & maternal
15.8
deaths
15.8.1. 5 years and above to below 10 years

15.8.2. 10 year and above to below 19 years

15.8.3. Adult 19 years and above

15.9. Total In-transit Deaths :Excluding infant & maternal deaths

15.9.1. In-transit Deaths: 1 year and below 5 years

15.9.2. In-transit Deaths: 5 years and above to below 10 years

15.9.3. In-transit Deaths: 10 year and above to below 19 years

15.9.4. In-transit Deaths: Adult 19 years and above

Part E Quality Control

QA (Quality Assurance) & BEMMP (Biomedical Equipment
M16
Management & Maintenance Program)
16.1 EQAS Compliance
Page 20 of 21
 Total number of Haematology tests registered under External Quality Assurance
16.1.1.
Scheme (EQAS)
16.1.2. No. of registered Haematology tests reported EQAS Compliant
Total number of Biochemistry tests registered under External Quality Assurance
16.1.3.
Scheme (EQAS)
16.1.4. No. of registered Bio chemistry tests report EQAS Compliant
Total Quantity of Bio medical waste generated in Kg for the month - (All Yellow, Red,
16.1.5.
white & Blue)
16.1.6. Total Quantity of General waste generated in Kg for the month

16.2 Biomedical Equipment Management & Maintenance Program

16.2.1. Total number of breakdown calls reported for the month

16.2.2. Total number of breakdown attended for the month

Numbers Numbers
Facility reported during reported during
Data Item the month the month
Code
(In-facility) (Outreach)

16.2.3. Number of visit made by the service engineer/ BME for the month
Updated as on 01-05-2025

Signature of report compiler Signature of Facility Incharge

Date : Date:

Page 21 of 21