PEN+ Supervision Checklist - October 2023-ARHB

PEN-Plus Project Supportive Supervision

Checklist
s.n Indicators/Activities Write findings Remark
1. Initial discussion With Medical Yes No
Director/CEO/ Focal person (On the
progress of the project)
2. Renovation completed? (If not Yes No
completed, Put the remaining things
on remark or in a separate page)
3. Number of dedicated room for PEN
Plus
4. Number of dedicated room for PEN
5. Number of Furniture available in the  Table:_______
clinic  Chair:_______
(Write in the remark column about  Patient examination couch:_____
proper utilization of equipment)  Computer:________
 TV:________

6. Number of Key equipment in the  BP apparatus:________

clinic  Stethoscope:_________
(Write in the remark column about  Weight scale:_________
proper utilization of the equipment)  Height scale:_________
 Measuring tape:_________
 Glucometer:_________
 Examination Hammer:_________
 Echocardiography:_________
 Peak flow meter:_________
 Monofilament:_________
 Spirometry:_________
7. Trained Professionals for the site Yes (# of trained) No (write remark)
 PEN Plus basic training
 Training on Echocardiography
 Training on ECG
8. Number of health professionals GP: _________
currently providing PEN-plus service Nurses: _________
Project officer/ data personnel: ______
Social worker: _________
9. Check availability of guidelines &
protocols (even soft copy) List what is
being used
10. Total Number of patients seen in
each OPD (PEN Plus)
11. Time allocated for each patient
12. Is there separate counseling room for Yes No (remark)
psychosocial support
13. Comment on the patient
communication and patient approach
appropriateness
14. Is the training center ready Yes No (remark)
15. Care coordination of PEN-Plus clinic  Case consultation/transfer: Yes No

with other departments of the  Data sharing: Yes No
hospital (PEN, Other OPDs, IPD,  Early linkage /time specific/: Yes No
Emergency) including cooperation of  Resource sharing: Yes No
other health professionals to work  Resources of PEN Plus bring difference for other
with PEN-Plus Trained Professionals services: Yes No
16. Other service providers oriented on Yes No
PEN Plus by PEN Plus team
17. Data completeness of patients on Take 20 sample charts
Summary, Intake and follow-up forms
18. Documentation of copy of Patients Take 20 sample charts
information in the suspension file
19. Functionality of PEN-Plus Equipment:
(list equipment that are not
functioning well and the reasons)
20. Backlog presence /Presence of
patients information not copied and
documented in the suspension file
box
21. Registration on Cohort Registration Yes No (remark)
Book
22. Collect Data from Cohort Registration cases Jan 01-Mar Apr 01-June July 01-Sep
book for each cases 31/2023 30/2023 30/2023
RHD
T1DM
T2DM
HTN
CHF
Asthma
COPD
Others
23. Check control status of patients in
the reporting period from the cohort
registration
24. Check the completeness of the
registration book (follow-ups, all the
indicators for each patients is
properly filled, List those patients
that are not properly registered or
has incomplete information)
25. Proper registration on Follow Up Yes No (remark)
Appointment Sheet - Total Number of patients
registered on the Follow-up
sheet per diagnosis: ______
26. Proper registration on Social Support Yes No (remark)
Registration Book at every visit (All
the support including counseling,
psychological, nutritional,
Financial….)
27. Psychosocial support: how do they
solve patients problems when they
don’t fulfill the criteria set to be
eligible for the support)
28. Number of patients registered for
psychosocial support per the type of
support received (list)
29. Registration on Echocardiography: Yes No
(Echo given in every departments in
Order
the hospital)
Report format
Evaluation Log Book
30. Number of patients registered to
receive Echo service
31. Collect Patient data from NCD Jan 01 – Mar 31/2023: ______
OPD/PEN patients April 01 – June 30/2023: ______
July 01 – Sep 30/2023: ______
32. Number of PEN Plus eligible patients
still in PEN clinic, write reason for not
enrolled to PEN Plus in remark
33. Proper documentation of Tally Sheet Yes No
in the file-box
34. Formal Health Education availability/ Yes No
Proper documentation
35. Formal Group Support Meeting Yes No
Minute documentation
36. Conducted Catchment Area Meeting/ Yes No
Proper Documentation of minute
37. list missing item from the “must to
be available medications” as per the
PEN Plus lists (Check the list)
38. list missing item from the “must to
be available reagents” as per the
PEN Plus lists (Check the list)
39. Write reasons for unavailability of the
above medications & reagents
40. Staff orientation on PEN Plus (Check Number of orientation sessions: ____
documentations) Number of participants: ______
41. Supports related to Health centers Human resource related support: ____
(write number) Equipment support: ______
Patient linkage strategy: ______
42. The Challenges faced so far and Challenges:
Mitigation mechanisms used to
counter those challenges
Mitigation Strategy:
43. Lesson Learnt so far
44. Case stories/Success stories/ best

practice
To be filled by the supervising team after the completion of the supervision

45. Signed an action plan in the presence Yes No Attach the action plan
of all concerned parties After final
meeting with all relevant
stakeholders
46. JSS Report developed and shared Yes No Attach the report

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PEN-Plus Project Supportive Supervision

6. Number of Key equipment in the  BP apparatus:________

15. Care coordination of PEN-Plus clinic  Case consultation/transfer: Yes No

43. Lesson Learnt so far

44. Case stories/Success stories/ best

To be filled by the supervising team after the completion of the supervision

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