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USAID / BASICS

Rapid Integrated Health Facility Assessment

1. OBSERVATION CHECKLIST - SICK CHILD

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{PRONUM} Province/Dist.Number ## (F9) Prov.Name {PRONAME} ____________________

{HWCAT} HW category # (1=Physician, 2=Nurse, 3=Midwife/MCH nurse,

4=Health assistant)

{FACNUM} Facility Number ## (F9) Facil.Name {FACNAME} ____________________

{FACTYPE} Facility type # (1=Hospital, 2=Health center, 3=Health Station)

{FACSTAT} Facility status # (1=Public, 2=Private)

{INUM} Interviewer no. ## {CHILDAGE} Child's age ## {CHILDNUM} ID No. ##

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1. What reason does the caretaker give for bringing the child

to the health facility?

(CODE 1 ALL RESPONSE TICKED)

{DIAR} Diarrhea/vomiting #

{FEV} Fever/malaria #

{PNEU} Difficulty breathing/cough/pneumonia #

2. Does the health worker ask of the age of the child or

have the age available? (1=YES, 2=NO)

{AGE} Age...................................................... #

{WEIGHT} 3.a Is the child weighed?. ............................. #

{PLOTWT} .b Is the child's weight plotted on a growth chart? ... #

{TEMPC} 4. Is the child's temperature checked?................. #

Does the health worker ASK about (or does the caretaker REPORT):

Danger signs: (1=YES, 2=NO)

{DRINK} 5. Not able to drink or breatfeed? .... #

{VOM} 6. Vomits everything? ................. #

{CONV} 7. Convulsions? ....................... #

{CONSC} 8. Change in consciousness/lethargic .. #

(1=YES, 2=NO)

{HDIAR} 9.a Diarrhea? .......................... #

{DURDIAR} .b For how long? ...................... #

{HBLOOD} .c Is there blood in the stool? ....... #

{HCOUGH} 10.a Cough or difficult breathing? ...... #

{DURCOUGH} .b For how long? ..................... #

{HFEV} 11.a Fever? ............................. #

{DURFEV} .b For how long? ...................... #

{HEAR} 12.a Ear problems? ...................... #

{PAINEAR} .b Ear pain? .......................... #

{DISEAR} .c Ear discharge? ..................... #

{DUREAR} .d IF YES, for how long? .............. #

Does the health worker perform these EXAMINATION tasks:

(1=YES, 2=NO)

{LETH} 13. Look for lethargy or unconsciousness? ... #

{OBDRINK} 14. Observe drinking or breastfeeding? ...... #

{SKIN} 15. Pinch the skin of abdomen? .............. #

{EYES} 16. Look for sunken eyes? ................... #

{SHIRT} 17. Raise the shirt? ........................ #

{RESPRATE}18. Count breaths/minute? ................... #

{CHEST} 19. Look for chest indrawing? ............... #

{NECK} 20. Look or feel for stiff neck? ............ #

{RASH} 21. Look for generalised rash? .............. #

{NOSE} 22. Look for cough, runny nose or red eyes? . #

{EARPUS} 23. Look for pus from ear? .................. #

{EARSWEL} 24. Feel for swelling behind ear? ........... #

Malnutrition:

{WAST} 25. Undress and look for wasting? ........... #

{PALLOR} 26. Look for palmar or conjunctival pallor? . #

{EDEMA} 27. Look for edema of both feet? ............ #

{KEYSIGN} A. All danger signs (Q.5 to Q.8 [or Q.13]) assessed? # (1=YES, 2=NO)

{KEYSYMP} B. All main symptoms (Q.9 to Q.12) assessed? ....... # (1=YES, 2=NO)

{KEYDIAR} C. Number of diarrhea assessment tasks completed? .. # (0 to 5)

{KEYARI} D. Number of ARI assessment tasks completed? ....... # (0 to 4)

{KEYFEV} E. Number of fever assessment tasks completed? ..... # (0 to 4)

{KEYNUT} F. Nutritional status correctly assessed? .......... # (1=YES, 2=NO)

Immunization and Screening

(1=YES, 2=NO)

{ACHCARD} 28.a Does the HW ask for the child's immunization card? ... #

If NO, go to question 29

{CHCARD} .b If YES, does the child have the card? ................ #

{CREFVAC} .c Is the child referred for vaccination: # (1=Today, 2=Another day,

3=Not referred, 4=Up to date)

29.a Does the health worker ask for

{AMCARD} the caretaker's vaccination card? ......# (1=YES, 2=NO, 9=N/A if

father = caretaker)

If NO or N/A, go to question 30

{MCARD} .b If YES, does mother have the card? .... # (1=YES, 2=NO)

{MREFVAC} .c Is the mother referred for vaccination: # (1=Today, 2=Another day,

3=Not referred, 4=Up to date)

Diagnosis and treatment:

How does the health worker classify the child?

(1=YES, 2=NO)

{SDIAR} 30. Simple diarrhea .................. #

{SDEHYD} .a Severe dehydration................ #

{MDEHYD} .b Some dehydration ................. #

{NODEHYD} .c No dehydration ................... #

{DYS} 31. Dysentery ........................ #

{PDIAR} 32. Severe persistent diarrhea ....... #

{SPDIAR} 33. Persistent diarrhea .............. #

{SPNEU} 34. Severe pneumonia ................. #

{PNEUMO} 35. Pneumonia ........................ #

{COLD} 36. Upper respiratory inf.(cough/cold) #

{SMALNUT} 37. Severe malnutrition/anemia........ #

{MODMAL} 38. Moderate malnutrition/anemia...... #

(1=YES, 2=NO)

{SFEVER} 39. Very severe febrile disease ...... #

{MALA} 40. Malaria .......................... #

{SMEASL} 41. Severe complicated measles ....... #

{CMEASL} 42. Complicated measles .............. #

{MEASLES} 43. Measles .......................... #

{OFEVER} 44. Fever, other cause ............... #

{SPEC44} Specify ____________________

{MASTO} 45. Mastoiditis ...................... #

{ACEAR} 46. Acute ear infection .............. #

{CHREAR} 47. Chronic ear infection ............ #

{NODIAG} 48. No diagnosis ..................... #

If validation is performed:

(1=YES, 2=NO)

{KEYCLAS} G.a Health worker classification agrees with validator? #

{KEYSCLAS}G.b Severely ill children classified correctly? ....... # (9= N/A)

What does the health worker administer or prescribe for the child

(1=YES, 2=NO)

{IMREF} 49. Immediate referral? ............. #

{MALINJ} 50. Antimalarial injection .......... #

{MALTAB} 51. Antimalarial tablets/syrup ...... #

{ASP} 52. Paracetamol/Aspirin ............. #

{BATH} 53. Tepid bath ...................... #

{ABINJ} 54. Antibiotic injection ............ #

{ABTAB} 55. Antibiotic tablets/syrup ........ #

{VITA} 56. Vitamin A or vitamins ........... #

{ORS} 57. ORS/RHF ......................... #

{ANTIDIA} 58. Antidiarrheal/antimotility ...... #

{METRO} 59. Metronidazole tablet or syrup ... #

{DKTAB} 60. Tablet or syrup, unknown type ... #

{DKINJ} 61. Injection, unknown type ......... #

{NONE} 62. None ............................ #

{OTHER63} 63. Other ........................... #

{SPEC63} (Specify) __________________

(1=YES, 2=NO, 9=N/A)

{KEYMED} H. Is the medication appropriate for the diagnosis? ..... #

{KEYDIAAP}I.a Diarrhea case received appropriate medication? ....... #

{KEYARIAP}I.b Pneumonia case received appropriate medication? ...... #

{KEYMALAP}I.c Malaria case received appropriate medication? ........ #

If validation is performed:

(1=YES, 2=NO, 9=N/A)

{KEYTT} J.a Is the child treated correctly? .............. #

{KEYREF} J.b Severe classification correctly referred? .... #

{KEYPNETT}J.c Pneumonia case correctly treated? ............ #

{KEYDIATT}J.d Diarrhea case correctly treated? ............. #

{KEYMALTT}J.e Malaria case correctly treated? .............. #

Interpersonal communication:

For all oral medications:

(1=YES, 2=NO, 9=N/A))

64.a Does the health worker explain how

{EXPMED} to administer medications/ORS? .............. #

.b Does the health worker demonstrate how

{DEMMED} to administer oral medications/ORS? ......... #

.c Does the health worker ask an open-ended

{ASKQES} question to verify the comprehension......... #

{KEYTASK} K. Number of treatment tasks performed? ........ # (0 to 3)

(1=YES, 2=NO)

65. Does the health worker explain when

{EXPFUP} to return for follow-up? .................... #

66. Does the health worker explain the need to

{EXPLIQ} give the same quantity/more liquid at home?.. #

67. Does the health worker explain the need to

{EXPFEED} continue feeding or breast-feeding at home?.. #

68. Does the health worker tell the caretaker to bring

the child back for the following signs?

(1=YES, 2=NO)

{NODRINK} Child is not able to drink or drinking poorly .... #

{NOBF} Child is not able to breast-feed/eat ............. #

{CSICK} Child becomes sicker ............................. #

{CFEV} Child develops a fever ........................... #

{CFASTB} Child develops fast or difficult breathing ....... #

{CBLOOD} Child develops blood in the stool ................ #

{CLETH} Child in inconsciousness/lethargic ............... #

{NUTAD} 69. Does the health worker give the caretaker any advice

on nutrition? .................................... #

{KEYCOM} L. Are at least 3 of the Q.68 messages circled? ..... #

{DUROBS} Duration of observation: (minutes) ............... ##

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