Back to Health Facility Assessment Tools
Back to Monitoring & Evaluation
Service Provision Assessment
[YEAR]
|
STI Patient Consultation Observation |
|
IDENTIFICATION | |
|
Name of the facility_____________________________ Facility Location________________________________ Code of the facility Type of Health Facility * : (1 = Hospital; 2 = Health Center, 3 = Dispensary; 4 = Maternity/Nursing Home; 5 = Clinic) |
|
| Position of person interviewed * : ( 1= Manager/Facility Administrator; 2 =
Physician; 3 = Professional Nurse/Midwife; 4 = Auxillary Nurse; 5 = Clinical
Officer; 6 = Extension Worker; 96 =Other___________)
Sex of health worker: (1 = female; 2 = male) Assessment number Sex of patient: (1 = female; 2 = male) |
|
| Date: |
Day Month Year. . . . . . . . . . . . . . |
|
Name of the interviewer_____________________ |
Interviewer Code . . . . . . . . . . . . |
| Beginning time |
Hour Minutes |
* Country specific categories should be used
ASSESSOR INSTRUCTIONS: OBTAIN PERMISSION FROM THE PATIENT AS WELL AS THE HEALTH WORKER BEFORE BEGINNING TO ASSESS THE INTERACTION BETWEEN THEM. BE AS DISCREET AS POSSIBLE DURING THE ASSESSMENT AND DO NOT TAKE PART IN THE INTERACTION IN ANY WAY. MAKE SURE THAT THE HEALTH WORKER KNOWS THAT YOU ARE NOT THERE TO EVALUATE HIM/HER AND THAT YOU ARE NOT AN "EXPERT" TO CONSULT DURING THE SESSION. TRY TO SIT BEHIND THE PATIENT, BUT IN A POSITION NOT DIRECTLY IN FRONT OF THE HEALTH WORKER. TAKE NOTES AS FAST AS POSSIBLE. FOR EACH OF THE QUESTIONS LISTED BELOW, CIRCLE THE ANSWER THAT MOST APPROPRIATELY REFLECTS YOUR ASSESSMENT OF WHAT HAPPENED DURING THE INTERACTION.
READ TO HEALTH WORKER: Hello. I am representing the Ministry of Health. We are carrying out a survey of health facilities that provide services to women and children with the goal of finding ways to improve service delivery. I would like to observe your consultation with this patient in order to better understand how health care is provided in this country. This information is completely confidential. You may choose to stop the interview at any time. May I continue?
| No. | QUESTIONS |
CODING CLASSIFICATION |
GO TO |
| 100a | PERMISSION RECEIVED FROM HEALTH WORKER. | YES 1
NO 2 |
STOP |
READ TO CLIENT: Hello. I am representing the Ministry of Health. We are carrying out a survey of health facilities with the goal
of finding ways to improve service delivery. I would like to observe your consultation with this health worker in order to better
understand how health care is provided in this country. This information is completely confidential and will not affect the level
of care your receive here now or in the future. After the consultation, my colleague would like to speak with you about your
experiences here today. You may tell me to stop the interview at any time. May I continue?
NO 2
100b
PERMISSION RECEIVED FROM CLIENT.
YES 1
STOP
| SECTION 1. CONSULTATION CHARACTERISTICS | |||
| 101 | WHAT IS THE PRESENTING STI COMPLAINT?
(CIRCLE ALL APPLICABLE) |
LOWER ABDOMINAL PAIN A
NON-FOUL SMELLING GENITAL DISCHARGE B FOUL SMELLING GENITAL DISCHARGE C BURNING PAIN ON URINATION D REDNESS/INFLAMMATION E SWELLING IN GENITAL AREA F GENITAL SORES/ULCERS G GENITAL WARTS H BLOOD IN URINE I LOSS OF WEIGHT J IMPOTENCE K NO SYMPTOMS L REFERRED TO FACILITY M PRESENCE OF PUBIC LICE N OTHER___________________________ X |
|
| 102 | WHAT OTHER SIGNS/SYMPTOMS ARE IDENTIFIED?
(CIRCLE ALL MENTIONED) |
ABDOMINAL PAIN A
GENITAL DISCHARGE B FOUL SMELLING DISCHARGE C BURNING PAIN ON URINATION D REDNESS/INFLAMMATION E SWELLING IN GENITAL AREA F GENITAL SORES/ULCERS G GENITAL WARTS H BLOOD IN URINE I LOSS OF WEIGHT J IMPOTENCE K NO SYMPTOMS L REFERRED TO FACILITY M OTHER___________________________ X |
|
| 103 | DOES THE PROVIDER ASK OR THE PATIENT REPORT THE
FOLLOWING INFORMATION: (QUESTION NOT CLEAR)
a) THE NATURE OF THE PRESENT SYMPTOMS? b) THE ONSET OR DURATION OF THE SYMPTOMS? c) THE CLIENT'S HISTORY OF RECENT SEXUAL CONTACTS? |
YES NO
NATURE OF SYMPTOMS 1 2 ONSET OF SYMPTOMS 1 2 RECENT SEX 1 2 |
|
| 104 | DURING ANY EXAMINATION, ARE THE PATIENT'S GENITALS FULLY
EXPOSED, WITH THE FEMALE PATIENT LYING DOWN?
a) DID THE HEALTH WORKER EXPLAIN TO THE CLIENT WHY IT IS IMPORTANT TO CARRY OUT A PHYSICAL EXAMINATION? |
YES 1
NO 2 YES 1 NO 2 |
|
| 105 | ARE EXAMINATION GLOVES USED? | YES 1
NO 2 |
|
| 106 | ARE THE EXTERNAL GENITALIA THOROUGHLY EXAMINED FOR
DISCHARGE AND LESIONS, I.E.
FOR UNCIRCUMCISED MEN, IS THE FORESKIN RETRACTED? FOR WOMEN, ARE THE LABIA SEPARATED AND INSPECTED? |
YES 1
NO 2 |
|
| 107 | IS THE PATIENT A WOMAN? | YES 1
NO 2 |
201 |
| 108 | IS A SPECULUM EXAMINATION PERFORMED?
a) DID THE HEALTH WORKER EXPLAIN TO THE CLIENT WHY HE/SHE IS DOING A SPECULUM EXAMINATION? |
YES 1
NO 2 YES 1 NO 2 |
110 |
| 109 | IS AN ADEQUATE LIGHT SOURCE USED? | YES 1
NO 2 |
|
| 110 | IS A BIMANUAL EXAMINATION PERFORMED?
a) DID THE HEALTH WORKER EXPLAIN TO THE CLIENT WHY A BIMANUAL EXAMINATION IS NEEDED? |
YES 1
NO 2 YES 1 NO 2 |
|
| SECTION 2. LABORATORY TESTS | |||
ASK HEALTH WORKER ABOUT TESTS AFTER CONSULTATION IF NECESSARY.
| LAB TEST | 201. IS TEST OBTAINED? | 202. IS TEST RESULT AVAILABLE ON CONSULTATION DAY? | 203. IS TEST RESULT AVAILABLE BEFORE HEALTH WORKER DECIDED ON RX? |
| a) Gram stain | YES 1
NO 2 b |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| b) Dark field microscopy | YES 1
NO 2 c |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| c) RPR/VDRL | YES 1
NO 2 d |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| d) TPHA | YES 1
NO 2 e |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| e) Wet mount | YES 1
NO 2 f |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| f) HIV-1 Elisa | YES 1
NO 2 g |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| g) HIV-2 Elisa | YES 1
NO 2 h |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| h) Rapid HIV | YES 1
NO 2 i |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| i) Other
___________________ |
YES 1
NO 2 301 |
YES 1
NO 2 DON'T KNOW 8 |
YES 1
NO 2 DON'T KNOW 8 |
| No. | QUESTIONS |
CODING CLASSIFICATION |
GO TO |
| SECTION 3. DIAGNOSIS AND TREATMENT | |||
| 301 | ASK THE HEALTH WORKER WHAT HIS/HER DIAGNOSIS IS AND RECORD IT. | _____________________________________
_____________________________________ |
|
| 302 | ASK THE HEALTH WORKER WHAT THERAPY HE/SHE IS
PRESCRIBING/PROVIDING TO THE PATIENT AT THIS CONSULTATION
AND RECORD:
DRUG 1 PRESCRIBED: |
AMOXYCILLIN 01
AQUEOUS CRYSTALLINE BENZYLPENICILLIN 02 AUGMENTIN 03 BENZATHINE PENICILLIN 04 CEFTRIOXONE 05 CIPROFLOXACIN 06 CLOTRIMAZOLE 07 DOXYCYCLINE 08 ERYTHROMYCIN 09 KANAMYCIN 10 METRONIDAZOLE 11 NORFLOXACIN 12 NYSTATIN 13 PROBENICID 14 PROCAINE BENZYL PENICILLIN 15 RIFAMPICIN 16 SPECTINOMYCIN 17 SULFADIAZINE 18 SULFAMETHOXAZOLE 19 TETRACYCLINE 20 THIAMPHENICOL 21 TRIMETHOPRIM 22 OTHER____________________________ 96 DON'T KNOW 98 NO DRUG PRESCRIBED 95 |
317 |
| 303 | WHAT DOSAGE IS PRESCRIBED? | 100 MG 01
125 MG 02 160 MG 03 250 MG 04 400 MG 05 500 MG 06 800 MG 07 1 PESSARY 08 1 G 09 1.5 G 10 2 G 11 2.5 G 12 3.5 G 13 1 TABLET 14 2 TABS 15 2.4 MEGAUNITS 16 1.2 MILLION 17 50,000 UNITS PER KG 18 OTHER___________________________ 96 DON'T KNOW 98 |
|
| 304 | WITH WHAT FREQUENCY IS THE DRUG PRESCRIBED? | STAT 1
DAILY 2 TWICE A DAY 3 THREE TIMES A DAY 4 FOUR TIMES A DAY 5 WEEKLY 6 OTHER___________________________ 7 DON'T KNOW 8 |
|
| 305 | WHAT IS THE PRESCRIBED ROUTE FOR DRUG 1? | INTRAMUSCULARLY 1
ORALLY 2 TOPICALLY 3 INTRAVAGINALLY 4 DON'T KNOW 8 |
|
| 306 | WHAT IS THE DURATION OF TREATMENT IN DAYS OR WEEKS? |
DURATION IN DAYS. . . . . . . . DURATION IN WEEKS
NOT KNOWN 98 |
|
| 307 | DRUG 2 PRESCRIBED: | AMOXYCILLIN 01
AQUEOUS CRYSTALLINE BENZYLPENICILLIN 02 AUGMENTIN 03 BENZATHINE PENICILLIN 04 CEFTRIOXONE 05 CIPROFLOXACIN 06 CLOTRIMAZOLE 07 DOXYCYCLINE 08 ERYTHROMYCIN 09 KANAMYCIN 10 METRONIDAZOLE 11 NORFLOXACIN 12 NYSTATIN 13 PROBENICID 14 PROCAINE BENZYL PENICILLIN 15 RIFAMPICIN 16 SPECTINOMYCIN 17 SULFADIAZINE 18 SULFAMETHOXAZOLE 19 TETRACYCLINE 20 THIAMPHENICOL 21 TRIMETHOPRIM 22 OTHER____________________________ 96 DON'T KNOW 98 NO DRUG PRESCRIBED 95 |
317 |
| 308 | WHAT DOSAGE IS PRESCRIBED? | 100 MG 01
125 MG 02 160 MG 03 250 MG 04 400 MG 05 500 MG 06 800 MG 07 1 PESSARY 08 1 G 09 1.5 G 10 2 G 11 2.5 G 12 3.5 G 13 1 TABLET 14 2 TABS 15 2.4 MEGAUNITS 16 1.2 MILLION 17 50,000 UNITS PER KG 18 OTHER__________________________ 96 DON'T KNOW 98 |
|
| 309 | WITH WHAT FREQUENCY IS THE DRUG PRESCRIBED? | STAT 1
DAILY 2 TWICE A DAY 3 THREE TIMES A DAY 4 FOUR TIMES A DAY 5 WEEKLY 6 OTHER___________________________ 7 DON'T KNOW 8 |
|
| 310 | WHAT IS THE PRESCRIBED ROUTE FOR DRUG 2? | INTRAMUSCULARLY 1
ORALLY 2 TOPICALLY 3 INTRAVAGINALLY 4 DON'T KNOW 8 |
|
| 311 | WHAT IS THE DURATION OF TREATMENT IN DAYS? |
DURATION IN DAYS. . . . . . . . DURATION IN WEEKS. . . . . . . . NOT KNOWN 98 |
|
| 312 | DRUG 3 PRESCRIBED: | AMOXYCILLIN 01
AQUEOUS CRYSTALLINE BENZYLPENICILLIN 02 AUGMENTIN 03 BENZATHINE PENICILLIN 04 CEFTRIOXONE 05 CIPROFLOXACIN 06 CLOTRIMAZOLE 07 DOXYCYCLINE 08 ERYTHROMYCIN 09 KANAMYCIN 10 METRONIDAZOLE 11 NORFLOXACIN 12 NYSTATIN 13 PROBENICID 14 PROCAINE BENZYL PENICILLIN 15 RIFAMPICIN 16 SPECTINOMYCIN 17 SULFADIAZINE 18 SULFAMETHOXAZOLE 19 TETRACYCLINE 20 THIAMPHENICOL 21 TRIMETHOPRIM 22 OTHER____________________________ 96 DON'T KNOW 98 NO DRUG PRESCRIBED 95 |
317 |
| 313 | WHAT DOSAGE IS PRESCRIBED? | 100 MG 01
125 MG 02 160 MG 03 250 MG 04 400 MG 05 500 MG 06 800 MG 07 1 PESSARY 08 1 G 09 1.5 G 10 2 G 11 2.5 G 12 3.5 G 13 1 TABLET 14 2 TABS 15 2.4 MEGAUNITS 16 1.2 MILLION 17 50,000 UNITS PER KG 18 OTHER___________________________ 96 DON'T KNOW 98 |
|
| 314 | WITH WHAT FREQUENCY IS THE DRUG PRESCRIBED? | STAT 1
DAILY 2 TWICE A DAY 3 THREE TIMES A DAY 4 FOUR TIMES A DAY 5 WEEKLY 6 OTHER___________________________ 7 DON'T KNOW 8 |
|
| 315 | WHAT IS THE PRESCRIBED ROUTE FOR DRUG 3? | INTRAMUSCULARLY 1
ORALLY 2 TOPICALLY 3 INTRAVAGINALLY 4 DON'T KNOW 8 |
|
| 316 | WHAT IS THE DURATION OF TREATMENT IN DAYS OR WEEKS?
|
DURATION IN DAYS. . . . . . . . DURATION IN WEEKS. . . . . . . . NOT KNOWN 98 |
|
| 317 | DRUG 4 PRESCRIBED: | AMOXYCILLIN 01
AQUEOUS CRYSTALLINE BENZYLPENICILLIN 02 AUGMENTIN 03 BENZATHINE PENICILLIN 04 CEFTRIOXONE 05 CIPROFLOXACIN 06 CLOTRIMAZOLE 07 DOXYCYCLINE 08 ERYTHROMYCIN 09 KANAMYCIN 10 METRONIDAZOLE 11 NORFLOXACIN 12 NYSTATIN 13 PROBENICID 14 PROCAINE BENZYL PENICILLIN 15 RIFAMPICIN 16 SPECTINOMYCIN 17 SULFADIAZINE 18 SULFAMETHOXAZOLE 19 TETRACYCLINE 20 THIAMPHENICOL 21 TRIMETHOPRIM 22 OTHER____________________________ 96 DON'T KNOW 98 NO DRUG PRESCRIBED 95 |
323 |
| 318 | WHAT DOSAGE IS PRESCRIBED? | 100 MG 01
125 MG 02 160 MG 03 250 MG 04 400 MG 05 500 MG 06 800 MG 07 1 PESSARY 08 1 G 09 1.5 G 10 2 G 11 2.5 G 12 3.5 G 13 1 TABLET 14 2 TABS 15 2.4 MEGAUNITS 16 1.2 MILLION 17 50,000 UNITS PER KG 18 OTHER___________________________ 96 DON'T KNOW 98 |
|
| 319 | WITH WHAT FREQUENCY IS THE DRUG PRESCRIBED? | START 1
DAILY 2 TWICE A DAY 3 THREE TIMES A DAY 4 FOUR TIMES A DAY 5 WEEKLY 6 OTHER___________________________ 7 DON'T KNOW 8 |
|
| 320 | WHAT IS THE PRESCRIBED ROUTE FOR DRUG 3? | INTRAMUSCULARLY 1
ORALLY 2 TOPICALLY 3 INTRAVAGINALLY 4 DON'T KNOW 8 |
|
| 321 | WHAT IS THE DURATION OF TREATMENT IN DAYS OR WEEKS? |
DURATION IN DAYS. . . . . . . . DURATION IN WEEKS. . . . . . . . NOT KNOWN 98 |
|
| 322 | WILL THE FINAL TREATMENT DEPEND ON THE RESULTS OF
LABORATORY TESTS?
(SUGGESTION THAT QUESTION IS LIMITED TO CASES WHERE THE TEST RESULTS WERE NOT AVAILABLE BEFORE Rx WAS DECIDED. QUESTION SHOULD THEN BE DIRECTED TO THE PROVIDER IF IT CAN NOT BE INFERRED FROM THE PROVIDER/CLIENT INTERACTION.) |
YES 1
NO 2 |
|
| 323 | DOES THE PROVIDER GIVE THE PATIENT A PRESCRIPTION OR
ADMINISTER THE MEDICATION(S)?
(SUGGESTION THAT WORD 'ADMINISTER' MAY BE MISLEADING. MAY WANT TO ASK ' PRESCRIPTION, DISPENSE, OR ADMINISTER' AND INCLUDE ADMINISTER MEDICATION, AND DISPENSED MEDICATION IN THE PRECODED RESPONSES OBSERVERS SHOULD BE INSTRUCTED TO TICK OR CIRCLE ALL THAT APPLIES SINCE ANY COMBINATION OF THE THREE MAY OCCUR.) |
PRESCRIPTION 1
MEDICATION 2 NOTHING 3 |
328 |
| 324 | ARE THE MEDICATIONS FREE OR DOES THE PATIENT HAVE TO PAY? | FREE 1
PAY 2 |
|
| 325 | IS THERE ANY DELAY (MORE THAN FOUR HOURS) BETWEEN THE
INITIAL CONSULTATION AND THE PROVISION OF TREATMENT?
(SUGGESTION THAT QUESTION BE CLARIFIED TO INDICATE WHETHER 'PROVISION OF TREATMENT' REFERS TO TIME THAT CLIENT RECEIVES THE PRESCRIPTION FROM THE PROVIDER OR WHEN HE/SHE GETS THE MEDICATION FROM THE FACILITY DISPENSARY/PHARMACY.) |
YES 1
NO 2 |
327 |
| 326 | HOW LONG? | OVER 4 HOURS, SAME DAY 1
NEXT DAY 2 LONGER 3 |
|
| 327 | DOES THE HEALTH WORKER INSTRUCT THE PATIENT ON THE IMPORTANCE OF COMPLETING THE FULL COURSE OF TREATMENT? | YES 1
NO 2 |
|
| 328 | IS THE RISK OF HIV/AIDS MENTIONED? | YES 1
NO 2 |
|
| 329 | ARE CONDOMS PROMOTED FOR STI/HIV PREVENTION? | YES 1
NO 2 |
|
| 330 | ARE CONDOMS PROVIDED/SOLD TO THE PATIENT? | YES, PROVIDED FREE 1
YES, PROVIDED WITH CHARGE 2 NO 3 |
332 |
| 331 | HOW MANY CONDOMS ARE PROVIDED OR SOLD? |
NUMBER. . . . . . . . . . . NOT KNOWN 98 |
|
| 332 | ARE INSTRUCTIONS ON CONDOM USE OFFERED? | YES 1
NO 2 |
|
| 333 | DOES THE PROVIDER DEMONSTRATE HOW TO PUT ON A CONDOM? | YES 1
NO 2 |
|
| 334 | IS THE PATIENT URGED TO REFER HIS/HER PARTNER(S) FOR
TREATMENT OR IS THE PATIENT GIVEN DRUGS FOR PARTNER?
(SUGGESTION TO ASSESS THE USE OF PARTNER NOTIFICATION CARDS, A STANDARD PROTOCOL IN MANY STI CLINICS. COULD CHANGE THE WORD 'URGED' TO ' COUNSELED' AND REPHRASE THE PRECODED RESPONSES TO READ: COUNSELED ONLY .......1 COUNSELED AND GIVEN PARTNER NOTIFICATION CARD/VOUCHER ........2 GIVEN MEDICATION.....3 NO ......4 |
REFER FOR TREATMENT 1
GIVEN MEDICATIONS 2 NO 3 |
|
| 335 | Is the patient referred to higher consultation | YES 1
NO 2 |
|
| 336 | Follow up/return date |
DAYS. . . . . . . . |
|
| SECTION 4. AFTER THE CONSULTATION | |||
| 402 | WAS PRIVACY MAINTAINED DURING THE CONSULTATION? | YES 1
NO 2 |
|
| 403 | MARK THE ENDING TIME |
HOUR MINUTES |
|
| COMMENTS:
| |||
Back to Health Facility Assessment Tools
Back to Monitoring & Evaluation