Checklist for Assessment of Outpatient Services in Hospitals in context of COVID-19

Hospital Name

Province District City Facility Code

Type of Facility Catchment Population Managed by Govt. Public Private Others

Administrator/MS Name Contact No. Email

Date of Assessment Assessment Done By Sign.

A. List of Outpatient Services (Please a mark)

Consultation Follow up Lab services Radiology (X- Minor PharmacyDispensing Nursing Counselling Rehabilitative Stores Admin. Offices Others
visits Ray, USG, MMG) Surgeries, services
Dressings

B. Departments Providing Outpatient Services (Please a mark)

Medicine and Surgery Eye ObGY Paediatrics ENT Dermatology Psychiatry Orthopedics Physiotherapy Dental Filter Clinics Others
allied and Allied
specialities

C. Number of Departments/Units providing Outpatient Services

DAILY 3 Days a Week 2 Days a Week Once a week

No. of Units Alternate Options No. of Units Alternate Options No. of Units Alternate Options No. of Units Alternate Options

D. Location & Layout Of OutPatient Department

Location of Outpatient Department Access/Entry to OPD

Independent Access Has to reach through hospital Some OPD services are within the
Part of main building Separate OPD Block Dual Arrangements concerned unit

Layout/Organization of OPD
Total Rooms No. of Rooms for Staff using a room in one Alternate option Rooms for other services Alternate Options Remarks
Consultation shift

Floor Arrangements
Ground Floor No. of Units on GF First Floor No. of Units on FF Others Stairs Elevator Ramp Alternate options
(Y/N) (Y/N) (Y/N) (Y/N) (Y/N)

Average Patients and Attendants

OPD/Day Male Females Paediatrics Quoue Patient Waiting area Capacity Alternate One directional movement Shift Mode
(#) (#) (#) (#) management/Token (Y/N) (#) Option (Y/N) (Y/N)

Amenities and Facilities attached/near Outpatient Block

Admin. Offices Medical Stores Attendant's Lounge Canteen Services Laundery Shops Mosque Parking area Others

Alternate Options for other services

E. Staffing

No. of staff on Permanat OPD duty Additional staff visiting OPD on specific days
Consultants Doctors Nurses Pharmacists Paramedics Admin Support Staff Consultan Doctors Nurses Pharmaci Paramedics Support Staff
(#) (#) (#) (#) (#) Staff (#) ts (#) (#) sts (#) (#)
(#) (#) (#)

Suggested Essential staff & Numbers per shift

F. WATER, SANITATION & HYGIEN (WASH) Services

functional Toilets for Patients functional Toilets for Staff Functional Hand washing Facilities for Functional HW facilities Soap is available (Y/N)
(#) (#) Staff (#) for patients(#)

G.Infection Prevention and Control (IPC)

IPC Focal Person for OPD IPC Focal Person Trained IPC assessment of OPD done before SOPs for Disinfection notified? SOPs of disinfection in practice?
notified (Y/N) resuming the OPD Services (Y/N) (Y/N)
(Y/N) (Y/Date)

Housekeeping Staff for disinfection notified Housekeeping Staff for disinfection Housekeeping Staff for disinfection Disinfection Supplies available (Y/N)
(Y/N) & Number Trained available per shift
(Y/N) & Date of training

H. Personal Protective Equipment

PPE Stock available PPE Stocks issued for each No. of PPE issued for medical staff No. of PPE issued for support staff per PPE replinishment mechanism at OPD
(Y/N) shift per shift shift
(Y/N)

Stock Available

Face Masks Gown N95 Face Shield Goggles Head Gear Gloves Shoe Cover Long Boat Utility Gloves Hand Sanitizer

I. Waste Manageement
Waste bins with Lid available in each Waste collection frequency Waste Disposal Responsible person for Waste disposal Waste disposal record is maintained
room mechanism
(Name /Designation)

J. Health Workers and Personnel Infection History

Total Number of staff contacted infection during last 3 months in the health Total Number of staff contacted infection during last 3
facility months at OPD