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The purposes of this guidelines are to provide a comprehensive guidance on MPA services and some essential activities to be provided by health center including services to be provided at health center and some main services to be provided at community.
This guidelines was also developed as a guidance for health center staff for implementation of their work, as well as for provincial and district health officers for their management work in accordance with the development of health sector.
It is also a basic and direction for central departments and institutions according to their respective role, especially for formulating training plan and necessary supply for functioning of health center.
This guidelines is also useful for all concerned stakeholders including health officers and donors to understand, involve and support activities of health centers in the whole country aiming to achieve the goals of the National Health Strategic Plan 2008-2015.
Phnom Penh, December 31, 2008 For Minister Secretary of State Prof.
Eng Huot ii Acknowledgement We would like to express our gratitude to H.
Chi Mean Hea Dr.
Mao Tann Eang Dr.
Ket Ly Sotha Dr.
Khuon Eng Mony Dr.
Mam Vichearith Dentist Hak Sithorn Dr.
Ka Oeun Chethra Dr.
Hen Sokun Chariya Dr.
Sok Sokun Deputy Director General for Health Chairperson Director of CNAT Deputy Chair Deputy Director of NMCHC Deputy Chair Deputy Director of HSD Permanent Member Deputy Director of DPM Member Deputy Director of CDC Member Deputy Director of NMCHC Member Deputy Director of Department of Personnel Member Deputy Director of NCMC Member Chief of Technical Bureau-Pediatric NH Member Chief of Oral Health Bureau-DPM Member Chief of Non-Communicable Control B.
Krang Sun Lorn Dr.
Chi Mean Hea 2.
Hong Rath Mony 4.
Background of health center and its coverage services.
Purpose of the Guidelines.
Roles and Responsibilities of a health center.
Roles and Duties of Health Center Staff.
For all Health Center Staffs.
Chief of Health Center.
Staff in-charge of OPD.
Staff in-charge of Antenatal Care and Postnatal Care.
Staff in-charge of Delivery.
Staff in-charge of Abortion and post abortion Care.
Staff in-charge of Family Planning.
Staff in-charge of Immunizations.
Staff in-charge of TB treatment.
Staff in-charge of Leprosy.
Staff in-charge of Malaria.
Staff in-charge of Dengue Fever.
Staff in-charge of Pharmacy at Health Center.
Services Delivery at Heath Center.
Outpatient Consultation Services OPD Services.
General Medicine Consultation and Treatment.
Follow Up and Referral Patient.
Sterilization of Medical Materials.
Mother, Newborn, Child and Reproductive Health Services.
Normal delivery and delivery with intervention.
Neonatal and young child care.
Integrated Management of Childhood Illness IMCI.
Safe abortion and post abortion care.
Sexually Transmitted Diseases and Gynecology.
Malaria and dengue fever.
Minor surgery and wound dressing.
Health Education and Health Promotion Services.
Guideline for Outreach Services.
Implementation of Outreach Services.
Coverage areas of outreach services.
Frequency of outreach services.
Package Services of Outreach Activity.
Monitoring and report on outreach services.
Development of Action Plan, Budget Plan, Monitoring and Evaluation.
Working program of the personnel.
Ensure 24 hour services.
Development of annual operational plan.
Budget management for health center.
Monitoring on implementation of quarterly plan.
Attending meeting at Operational District.
Organizing and attending meeting of Health Center Management Committee.
Organizing meeting of Village Health Support Group.
Demographic Link in responsible areas.
Hygiene, Health Care Wastes Management and Safe Water.
Safe disposal of wastes.
Water supply and sewage.
Recording of daily information registration list, making activity report and inventory list.
Development and Human Resources Management.
Ensure that health center staffs have been trained on proper techniques and skills.
Promotion the performance of staff.
Provision of continued education to community through members of Village Health Support Group.
Drug and Medical Equipment Management.
Medical Materials Management and Maintenance.
Community Based Health Insurance.
Health Center Management Committee.
Roles and Functions of the Health Center Management Committee.
Tasks of Health Center Management Committee.
Village Health Support Group.
Criteria for establishment of a health post.
Number and Name List of ODs, RHs, HCs and HPs.
Women tetanus toxic vaccination card.
Birth Spacing Appointment Client Card.
TB Patient Referral Form.
Health Center Discharge Form.
Report of HC1 on Out Patient Consultation.
Report of HC1 on Inpatient Activities.
Report of HC1 on Laboratory Activities.
Report of HC1 on Pre and Post-natal Examination and Delivery.
Report of HC1 on Birth spacing.
Report of HC1 on Activities of Immunizations Program.
Report of HC1 on Other Activities and Comments.
Report of HC1 on Zero Report.
Report of HC1 on Traffic Accident.
Essential Drug List for Minimum Package of Activities.
Daily Record of Drug and Medical Materials Consumption.
Monthly Record of Drug and Medical Materials Consumption.
Income-Expense Report of Drug-Medical Materials for Outreach Services.
Overstock Report of Drug-Medical Materials.
Emergency Kit for a Referral Patient.
Drawing of a Standard Health Center.
Drawing of a Standard Health Post.
Background of Health Center and Its Coverage Services In 1995, the Ministry of Health launched the reform of the health system in accordance with public administrative reform of the Royal Government of Cambodia.
The purpose of this reform was to improve the quality of services delivery to all people especially those living in remote areas through the implementation of the district health system.
Health coverage plan, as a part of the health sector reform, specifies the location and number of health center and referral hospital, and also defines responsible areas of these health facilities in providing health services to the people.
This new health system has been implemented since 1996 till now.
At the beginning, according to the health coverage plan, there were 71 operational districts and 942 health centers.
Currently, the number of operational district increases to 77 and number of health center increases to 960.
The provision of MPA services has been implemented over 10 years.
Annex-1: Number and Name List of ODs, HCs and HPs 2.
Purpose of the guideline The main objective of this guideline is to provide comprehensive guidance on various services of the "Minimum Package of Activities" and some main activities to be provided by health center in line with progress of the current health system, for at least in the next 5 years.
These services include main services to be provided in-side of the health center encompassing primary health care as well as main services to be provided at community level, especially outreach activities and community participation in the health care.
This guidelines is to be used at national, PHD and OD levels, as a direction for organizing, planning, training, monitoring, and supervision as well as for allocation of resources in order to improve services in terms of both quantity and quality at health center level including community level.
This guidelines is also developed for health workers in health center and community levels, as a principle for providing effective services.
The Hospital Services Department of the Ministry of Health is mandated to monitor and evaluate the performance of the health center for both in-side and outreach activities.
Evaluation of overall performance of health center will be held once a year within the 4 quarter by a joint working group whose members are from department of planningdepartment of hospital services and some other related departments.
Roles and Responsibilities of Health Center The role of the health center is to provide Minimum Package of Activities service to local people especially to the poor and vulnerable people.
These include quality mother-child and reproductive health service; communicable diseases control service, non-communicable diseases and other health problem services, health education and outreach activities services.
Besides, health center has also a role in taking into account quality improvement for its effectiveness according to the national policy on quality improvement in health sector consisting of 6 strategic activity plans as follows: 1.
Promotion of client rights 2.
Legislation and institutional management 3.
Inclusion of quality improvement in institution Health center should strengthen its health service delivery including preventive and curative services focusing on population need and in accordance with a quality standard.
Health center should focus on human resources development through refresher training or staff motivation.
Health center should well strengthen information system and referral system, and should have good governance, harmonization with development partners and community.
Annex-2: Prakas on management of health center located in or near referral hospital 2.
Organization Chart Each health center should have clear organizational structure for its management and function.
The following organization chart shows how to allocate the tasks.
The organizational chart below is model example and it may be varied upon number of staff in a 2 health center.
For example, in your health center there is staff in-charge of mental health or dental care.
Table 1 Chief In-charge of management - Health Center Management Committee - Village Health Support Group 1 Vice Chief In-charge of work as assigned by the chief 2 3 Registration and Information OPD adult and childand minor surgery Maternal and Child Health Immunization Medical Store and Laboratory 4 5 6 7 8 Other Services 3.
For any operational district where human resource is available, number of staff may be more than this; it can be up to 11 people.
The number mentioned above does not include number of staff working at health post.
Each Health post should have one nurse and one midwife.
Roles and duties of health center staff 4-1.
For all Health Center Staffs 4-1-1.
Roles: - Respect internal regulation and organizational chart of the health center including putting on medical uniform and ID card.
Involve in keeping good hygiene always in health center.
Annual inventory should be also completely made.
Chief of Health Center 4-2-1.
Duties in Details - Ensure that staff is permanently present at health center in both working time and on duty time 4 - - - Hold regular personnel meeting and attend monthly meeting at operational district Allocate tasks for all of health center staff including outreach services Immunization, epidemic disease control, follows up of chronic disease, etc.
Arrange patient referral and feed back system 4-2-3 Qualification - Be with technical skill, at least secondary nurse or secondary midwife - Be good professional conscience, honest and responsible for work - Be good tolerance and friendliness with staff and patients 4-3.
Staff In-charge of OPD 4-3-1.
Qualification: At least a secondary midwife licensed by the Ministry of Health.
Submit monthly report as required.
All services above should be provided both in health center and at outreach activity Immediate Postpartum Care: For mother: - Regularly take vital signs, hemorrhage and recovery of the uterus until mother becomes stable - Help mother to give breastfeeding - Provide health education, counseling, vaccine and vitamins properly For baby: - Apgar score: check and record 6 - Regularly monitor vital signs, sucking breast, general conditions, and umbilical cord Completely check baby: body weight, length, head size and other abnormalities Provision of vaccines: Learn more here, hepatitis-B, etc.
Follow up Postpartum Care All services above should be provided both in health center and at outreach activity For mother: - Check abdomen and vagina; provide iron tablet and tetanus toxic vaccination, information about family planning, counseling and health education - Provide health education, counseling, vaccines and vitamins properly - Provide or transfer for PMTCT service if necessary For baby: - Properly reared and weight gained, received vaccine on time 4.
Qualification - A secondary midwife certificate holder licensed by MoH, or a primary midwife licensed by the Ministry of Health under supervision of the secondary midwife.
Staff In-charge of Delivery 4-5-1.
Qualification: - A secondary midwife certificate holder licensed by MoH, or a primary midwife licensed by the Ministry of Health under supervision of the secondary midwife.
Staff In-charge of Abortion and Post Abortion Care 4-6-1.
Duties: For a health center where there is staff trained on abortion care: - Provide proper counseling and non-judgmental to partner regarding pregnancy, abortion, family planning, etc.
Qualification: - A secondary midwife licensed by the Ministry of Health and trained on abortion and post-abortion care 4-7.
Staff In-charge of Family Planning 4-7-1.
Qualification: - A secondary midwife certificate holder licensed by MoH, or a primary midwife licensed by the Ministry of Health under supervision of the secondary midwife.
Qualification: At least nurse or a primary midwife licensed by the Ministry of Health under supervision of chief of health center and was trained in this field.
Staff In-charge of TB Control 4-9-1.
Qualification: A secondary or primary nurse trained on TB control.
Qualification: A secondary or primary nurse trained in this field.
Staff In-charge of Leprosy 4-11-1.
Duties: - Diagnosis of leprosy - Provide treatment, make appointment for next visit, provide health education and counseling relevant to health center level - Provide counseling on confidentiality properly to patient - Take responsibility for request of supplies and maintain all supplies and medical materials to be used - Record all information in Record book and Patient Health Record, and submit monthly report 4-11.
Staff In-charge of Malaria 4-12-1.
Duties: - Do blood test Rapid Test or by Microscope for malaria parasite, if health center can do it - Provide treatment, make appointment for next visit, provide health education and counseling properly according to health center level - In case health center has no ability to treat, refer severe malaria patient to referral hospital after provide first dose treatment first aid.
Staff In-charge of Dengue Fever 4-13-1.
Duties: - Carefully examine on child in case of severe fever for many days as told by mother 888 poker deposit bonus code - - Rapidly check for dengue fever signs in order to refer patient to referral hospital on time Not to give Aspirin to the child, it is possible to give an appropriate dose of Paracetamol to reduce fever.
Please read Guideline on Dengue Fever Treatment of the National Program.
Provide education on cleaning of house and using mosquito net to prevent mosquito bitten 4-13-2.
Qualification: A staff who in-charge of OPD consultation.
Staff In-charge of Pharmacy at Health Center 4-14-1.
Duties: - Responsible for management of pharmacy at health center - Responsible for distribution of drug to patient based on prescription - respect regulation and organizational structure of the health center - Make daily-weekly-monthly-quarterly and yearly in-out report - Record in list and make balance of daily-weekly-monthly-quarterly consumption regularly, and report in case of out of stock.
Qualification: - A primary nurse or primary midwife licensed by the Ministry of Health.
Chapter 3: Service Delivery 1.
Services Delivery at Health Center 1-1.
Outpatient Consultation Services OPD Services Outpatient consultation services are essential for health center since it is the king neptunes casino no deposit bonus where health problems of people who came for consultation concerning their health can be identified.
These services can attract patients to utilize health center, if responsible personnel is skillful and possess good behavior.
Outpatient consultation should be at least provided by secondary midwife or nurse.
Services Provided at Outpatient Unit 1-1-1.
General Medicine Consultation and Treatment Health center provides consultation and primary care service of health problems which frequently occur such as: communicable diseases, noncommunicable diseases, chronic diseases, and emergency care.
Clearly confirm how to use medicine and advantage of illness follow up.
These documents should be always available and up to date.
Annex-3: Registration list for outpatient 12 1-1-2.
Patient Flow Patient flow is the arrangement of the flow within the health center for the patients.
This flow must be well arranged in order to avoid confusion patients don't know where to go and void waste of time.
Patient must be registered at reception 4.
Then, patient enter to consultation- 5.
Post partum care and reproductive health antenatal, birth spacing, delivery 3.
To provide an effective emergency service, health center staff must clearly know about emergency risk signs to be resuscitated, and must know well how to triage, how to resuscitate and how to refer the case.
Generally, this service is within outpatient service.
Follow Up and Referral Patient Health center is responsible for follow up of patients in its coverage areas.
A suspected case must be inquired in details about previous sickness and medical treatment history so that it is easy to identify clearly about health problems.
In this case, health center, especially staff in-charge of outpatient consultation, must know clear about services available at referral hospital.
Patient Refer Patient must be referred to referral hospital with a Referral Form, and if patient is in severe condition or has just received emergency care, there should have a health staff accompanies with.
In case the patient is injured of road accident, the Road Accident Report Form must be attached together with Referral Form.
Annex-4: Referral Form 1-1-5.
Ancillary Services At health centers, most of health staffs are not laboratory technicians.
They should, however, have simple ancillary services which can assist in determining health problems at the health center level.
The main ancillary services which should be done at the health center level include the following: 1.
Urine test by using dipstick for detecting proteins, pH, and glucose.
In case of suspected diabetes, a patient should be referred to a referral hospital.
Blood test by using rapid test as hemoglobin color scale to detect hemoglobin concentration in order to assess the level of paleness which will require treatment or referring.
Malaria test by using rapid test and send blood smear to laboratory department of a referral hospital to get confirmation of the diagnosis.
Tuberculosis test sputum testmake sputum smear, and then, send consider, texas holdem assistant tell to laboratory department of a referral hospital.
Pregnancy test by using dipstick.
This is called sputum collection on the spot.
This is called dawn sputum collection.
And the third learn more here collection should be done under direct observation of health staff.
To collect the best quality sputum and to avoid sputum getting infected by other microbes or germs, health center staff should explain the patient as follows: Tasks to be undertaken prior to sputum collection: Sputum collection is for detecting microbes and diagnosing the disease on time.
This purpose must be clearly explained to a patient by health staffs.
The lab form must be correctly filled.
The form will be sent to a laboratory department of a referral hospital with 3 sputum cups or smear of the patient.
Health staffs should tell patients to spit in sputum cup in order to avoid making the outside of the cup dirty.
Instruct them how to close the cup with it cap correctly.
Health staffs must clean titan poker 150 no hands with water and detergent.
A place for preserving sputum must be reserved for preserving sputum only.
If sputum collection was not done properly, the result of sputum examination may be false.
Likewise, if the smear was made too thick or too thin or heterogeneous, the result would be false too.
Slides must be put in order according to the written serial number.
Matching the number written on a sputum cup with the one written on the slide.
After that, open the cap of a sputum cup carefully, and then, put it on the aluminum tray.
Use bamboo or platinum stick for making smear - Procedure 1: The smear can be made by using bamboo stick by making the point of the bamboo stick rough.
After smearing, the already-used bamboo stick must be dipped into an alcohol-sand bottle prior to discarding it.
Before smearing, it is advised to burn the end part of Nikel string of platinum stick with Bigmensen flame or alcohol lamp until it becomes red, and leave it to cool off and then, use it to make smear.
After use, dip the platinum stick into an alcohol and sand bottle with the content of 300500 milliters, then burn it with the flame of Bigmensen or an alcohol lamp once more and then leave it to cool off.
Making all other smears must be done in compliance with the aforementioned procedures.
Hold the slide on the written-number part, and then smear the sputum in a spiral shape homogenously.
Making smear within 2 cm wide and 3 cm long but not exceed this size.
Leave the slide to get dry in a room with normal temperature.
Do use the fire flame to dry it.
Fill treatment form, patient form and then record the case in the list of tuberculosis patients and provide them with health education.
If the result of one time among the three—time sputum examined was BK positive, the patient should be referred to a referral hospital for other assessments.
In case the results of all three-time sputum examined were BK negative, the patient must be treated by using normal antibiotic for the period of 10 to 15 days.
If the result remains BK negative but x-ray indicated TB suspected sign, the patient must be treated for pulmonary TB with positive BK.
This is a common standard for malaria diagnosis.
The strategic policy and guidelines on volunteer confidential counseling and testing approved by the Ministry of Health in 1995 and revised it in 2002 and 2007.
Any institution in both public or private sectors providing 17 volunteer confidential counseling and testing services must seek permission from the Ministry of Health.
According to the 2003-2007 strategic plan on the prevention of HIV transmission and continuum of care, the Ministry of Health plans to increase VCCT centers up to 250 places in 2010 at referral hospitals, former district hospitals and some health centers.
Those officers are physicians and nurses who work at health centers.
And then, send them to have VCCT service, if they volunteer.
Providing counseling and supporting are very important.
It can help clients for solving some situations.
Counselors should refer a client who has HIV positive result to HIV-AIDS home care or continuum of care services treatment of opportunistic diseases and antiretroviral therapy nearby.
Inadequate cleaning of medical materials will cause transmission of germs from a person to another.
Each health center should have Autoclave for sterilization of medical materials.
Mother, Newborn, Child and Reproductive Health Services Standard Maternal, neonatal and child health care services at health center is responsible for provision of a good quality care for women at child bearing age, at adolescent, during pregnancy, during delivery, postnatal and neonatal.
For more details, read the description about ancillary services.
Antenatal Care ANC : Antenatal care should be done periodically 4 times at least.
First ANC Visit: should be done within first quarter of pregnancy age: - It is to confirm that woman is really being pregnant.
If real pregnancy, confirm whether it is a normal pregnancy or a hydatidiform mole or an ectopic pregnancy or threatened abortion or intrauterine fetal death.
Check for inverted nipples and provide treatment Discuss on birth spacing and birth preparedness, reconfirm about date of delivery and date of appointment, and advise woman to meet health service provider in case of necessary Provide emergency care and refer the woman to referral hospital on time.
Forth ANC Visit: should be done at term - Follow up check health status of mother and fetal growth - Detect for danger signs - Confirm about actual date of delivery and delivery facility - HIV-carried-women should be reminded about importance of delivery at hospital or at health center where PMTCT service is available.
Cesarean section may reduce risk of HIV transmission form mother to child compared with vaginal delivery however, cesarean section is not recommended for every of HIV-carried-womenand woman should be referred to deliver baby 21 - - at maternity facility where PMTCT service is available.
Further discuss about exclusive breastfeeding and other options of infant feedings please read National Guideline on PMTCTC, Chapter 5.
Discuss on post partum care, baby care at home, risk signs which may occur on mother and baby, return to health center when any problems or for birth spacing service when necessary.
Provide emergency care and refer the woman to referral hospital on time.
Antenatal Care for a Young Mother - Health service provider at health center may meet young pregnant woman adolescentseither she is married or not married; health service provider should provide her the service without any prejudgment about marital status.
She shall be provided a discussion and consultation using an easily understandable-simple language and she shall be encouraged to ask any question she wonder or concern about.
Any explanation, advice and support should be provided especially knowledge on infection prevention, birth spacing, and health promotion for mother and baby, nutrition and infant feeding.
Annex-6: ANC Register 1-2-2.
Pregnant women with HIV unknown status shall be tested for HIV at labor time.
In case of untrained midwife: attends normal delivery case, and refers the women on time to health center or to referral hospital where have enough capacity and ability.
Annex-8: Delivery Register 1-2-3.
Postpartum Care: Postpartum care is divided into two parts: immediate postpartum care and periodical postpartum care or 2 times at least.
Immediate postpartum care within 2 hours after delivery: - Observe mother every 15 minutes so that risk signs can be detected vaginal tear, paleness, fever, high blood pressure or low blood pressure, pulse, severe 22 - headache, dazzle.
Assess the amount of vaginal bleeding, uterine contraction firm or supple uterus.
If the women are in the good condition, they should be discussed and reminded about danger signs and advised to revisit health center immediately when problems happen.
Then the woman should be provided advice on post-natal care and personal hygiene, baby care, nutrition, birth spacing, and tetanus toxic vaccination if requires.
Location and relevant services i.
Provide health education to mother.
The mother should be consulted on birth spacing and contraceptive methods should be provided immediately if the woman chooses and use it voluntarily.
The mother should be encouraged exclusive breastfeeding until baby becomes 6 months, should be explained about baby care.
Annex-9: PNC register 1-2-4.
The main purpose of the program is to reduce morbidity, disability and mortality rate caused by 7 diseases tuberculosis, diphtheria, poliomyelitis, tetanus, whooping cough, measles and hepatitis B.
To achieve aforementioned goals, health staff shall: - Increase health education activity by mobilizing population on awareness of immunizations program is strongly enhanced.
Outreach activities should be done according to dimension and geographical status of the community.
Health centers shall have rotation plan of qualified health staff to the immunization unit.
These may be a solution of shortage of staff, and minimum immunizations are provided.
The policy of Ministry of Health should be used a guidance for determining the frequency and the date of outreach service.
When a plan of outreach activity is made, other integrated activities should be also considered, for instant, provision of supplementary vitamin A and study on nutrition.
Immunizations plan should be made in compliance with the following 5 stages: 1.
Estimate target population 2.
Estimate number of recipients of immunizations 3.
Calculate number of days to provide immunizations in each village and in each month 4.
Inform to each village precisely about date and time 5.
Make annual plan for immunizations 1-2-4-4 Vaccines available from the National Immunizations Program 1-2-4-4-1 Introduction: At present, vaccines which are available from National Immunizations Program includes BCG, DTC-HepB, HepB, Polio, Rouvax Measles and TT.
These kinds of vaccine are acknowledged by World Health Organization.
These vaccines can prevent Tuberculosis, Diphtheria, Pertusis, Hepatitis-B, Poliomyelitis, Measles, and Tetanus.
Therefore, children should be immunized with all kinds and a complete dose of these vaccines in compliance with National Immunization Program's calendar.
Spoiled vaccines are neither longer quality nor effective, thus no immunes system created although children are immunized.
Most of the vaccines are sooner spoiled because of: heat, sunshine and chemical elements such as soap, alcohol.
Preserve the vaccines in a place where temperature can be controlled and avoid aforementioned factors that spoil the vaccines.
The National Immunization Program defined the following main points about temperature for preservation of vaccines: 27 A.
Temperature: At health center level: it should be preserved for one week in the freezer and for one month in refrigerator, as long.
Materials Required for Preservation of the Vaccines: All kinds of vaccine require to be preserved in a suitable temperature and within a limited period.
Thus, some of the following preserving materials are required so that their effectiveness can be ensured: - Frozen rooms, cooled room at national level - Refrigerator, Freezers, Isotherm Box, Frozen box C.
Check label on the vaccine vial; dispose it of if over expiry date, and a vial without label is not recommended for use.
A removed or cracked on vial must be check, and dispose of if it is spoiled.
Shake the DDC, Hepatitis-B and Tetanus vaccine vial, before they are provided to target population.
Temperature must be checked for each step of cooling system handled with.
Principles of the Policy of National Immunization Program must be complied with for the vaccines which are kept for next time use.
Icepack should be put 15 minutes before the vaccines are put into the carrier.
Vaccines should be transported as quickly as possible, and a freezer or carrier with vaccines inside should be immediately placed in a shade area while taking a rest on the roadside.
Vaccines which can be used for next time should be returned into the freezer or refrigerator.
Vaccines must be preserved within +2 to +8oC, and temperature should be routinely checked every morning and evening using a temperature check sheet.
The disposable syringe, needle and cap must be disposed of in a safety box.
A filled safety box must be incinerated properly in an incinerator.
Never use DPT, DPT-HepB, HB and TT vaccines which were frozen.
If any suspicious, shake again.
VVM must exist on all of vaccine vials.
During the vaccination occasion, all vaccines must be always preserved in a vaccine carrier, even at health center.
Diluting water must be always kept together with vaccines in the vaccine carrier.
This information is available from store card, which each item was routinely recorded.
Store card can clearly identify: A The number of materials and vaccines received and distributed.
B The dates of receiving and distribution of materials and vaccines.
C The sources where materials and vaccines received from and distributed to.
Store card is more important for the remaining vaccines, since a direct and frequent count disturbs cooling system and may cause vaccines spoiled.
Therefore, store card must be recorded correctly, timely and precisely.
Safe injection is an action in which risk is not caused to recipients, service providers, and communities.
Note: The following actions should be taken by health staff so that safe immunizations are provided and waste of AD syringe can be reduced: 1.
Never move up or down piston of the syringes if not necessary.
Care must be taken for draw of vaccine to prevent many air get into AD syringe.
Never recap the needle after injection since it may cause of needle stick.
This figure is from WHO network for safety injection 5.
Safety box is necessary when vaccinations activity is carried out since safety is ensured when syringes, needles, sharp materials, piston caps and needle caps are dropped into the box.
It can burn hospital wastes and safety boxes well.
The full safety boxes must be collected and burnt in this incinerator.
Since SICIM is a high-temperature incinerator during burning over 800oCburning syringes and needles in this incinerator, therefore, toxic smokes can be reduced.
In addition, microbes contaminated on needle can also be killed.
All full safety boxes must be burnt in this SICIM incinerator.
At end of month: Actual remaining number should be clearly checked with number in the report and in store card, and quality should be also verified.
If not it should be provided as soon as possible, but click here later than one week after birth.
Nowadays, DTC-HepB vaccine is being used in stead of DTC.
Read annex-11: Child Growth Monitoring Chart 1-2-5-3 Anemia Control Program Overall view of direct and contributive interventions for prevention and control of anemia of iron-deficiency in Cambodia are: - Provision of supplementary daily iron tablets-acid folic to pregnant women and mothers of postpartum deposit codes 33 no casino bonus antenatal care and postpartum care at health facilities and at outreach service activity of health centers.
The vitamin A supplement should be distributed prior to starting of a season which may cause of problems while food-rich in vitamin A is in shortage, for instance, dry season April ~ Juneand during the common occurrence of measles or diarrhea.
The areas where severely affected by vitamin A deficiency are firstly prioritized for the distribution.
The whole country now is considered as vulnerable area and also is area for providing universal medicine.
Priority target groups are: - Children at 6 months to 5 years of age 6-59 months - Postpartum women not concerning baby feeding methodswithin 6 weeks Those main strategies are: - Screening and administration of vitamin A capsule at any contact with routine health services, including immunization and maternal health services - Universal vitamin A capsule supplementation twice a year around May and Novemberas part of regular outreach services.
Priority target groups are: - Children at 6 months to 12 years of age with measles clinical symptoms or at risk of contacting measles, severe malnutrition protein and energyand persistent diarrhea diarrhea over 14 days.
The main operational strategies are: - Diagnosis of disease and administration of vitamin A during consultation at health center and at referral hospital - Diagnosis of disease and administration of vitamin A during measles outbreak investigation and response.
Strengthen clinical and counseling skills of health workers through integrated management of childhood illness strategy enacted by the Ministry of Health.
The National Maternal and Child Health Center of the Ministry of Health will collect the information as well as conduct a study to explore the potential of food fortification with vitamin A.
Public health measures such as immunizations and sanitation services that address diarrhea, measles, and helminthes infections and malnutrition contribute to both directly and indirectly to vitamin-A deficiency reduction, and will be strengthened.
Provide support to women comply with the national protocols including counseling, giving ARV, birth spacing, safe sexual intercourse, infant feeding, prevention against other opportunistic infections, especially at postpartum.
Provide mental health support, share their anxiety-fear, and help them contact with community base care network or friend helps friend group.
Clarify about the importance of blood testing for husband or partner.
Encourage the HIV 38 infected women to deliver baby at hospital, follow up health condition and care for baby as need arises and periodically.
Provide ARV to baby Cotrimoxazole and HIV test for more details, read National Guidelines for PMTCT, Chapter 5.
For a very low-birth-weight baby under 1500g should be referred to a facility where special care is available.
For a baby within 1500-2500g or twin babies, if good conditions, daily care are necessary for them including breastfeeding if baby can suck, or using an alternative feeding method if baby cannot suck.
Mother or family should be trained on breastfeeding, kangaroomother care method, detection of risk signs and monitoring of baby health.
Support should be provided to mother or family until they can help their baby.
Follow up care for HIV positive mother and baby at postpartum.
Well collaborate and communicate with home-based care team and HIV carrier support group.
Therefore, the provision of integrated childhood illness consultation is essential for child survival.
Staff at health facility responsible for outpatient consultation has a main role to provide integrated management of childhood illness especially to all under-5 years children visiting to health facilities.
A birth spacing method should be provided to client after counseling, provision of right information and client decision-making without any force, any product promotion.
Client should be sufficiently informed about available birth spacing methods condom, pill, injection, IUD and Implant as well as permanent contraceptive methods such as tubal sterilization and vasectomy to avoid rumors misunderstanding and misuse.
If any of no deposit jerry bonus slot method is not available at health center, client should be informed a certain facility where the service is available and should be referred for the service.
The information must be filled in the Birth Spacing Register, Clinic Card, Client Card and Health Information System data.
An appointment for a regular continued contraception as well as health follow up for clients are important for provision of birth spacing services at health center.
Be referred to national guidelines on PMTCT for prevention of women of reproductive age from getting infected by HIV, prevention of HIV positive women from having unwanted pregnancy, voluntary confidential counseling and testing, and for health education.
Birth spacing service can be also provided to clients at community through community based distribution CBD.
Annex-12: Birth spacing register; Annex-13: Birth Spacing Appointment Client Card 40 1-2-10 Adolescent Reproductive Health Health service provider at health center should provide to adolescences of: - A support by explaining about risks which might happen on too-young mother during pregnancy although it is a wanted or a planned pregnancy.
Explain about socio-economical problems to avoid too-young women having pregnancy.
Activities: - Train women at community on self-examination of breast to prevent breast cancer - Refer the women to referral hospital in case they face any problems so that they can be treated on time.
Health center should have sufficient equipments, materials and measures required for the service i.
A safe abortion includes preduring and post abortion counseling, procedures of abortion, provision of birth spacing service and post abortion follow up care.
Those syndromes are as follows: 1.
Urethral discharge on the men 2.
Vaginal discharge on women 3.
Lower abdominal pain resulted from uteritis or salpingitis Method of clinical management of the above syndromes is described in details in the National Guideline on Syndromes-Based STD Clinical Management developed by the NCHADS and NMCHC.
A severe or incurred case should be transferred to family health clinic STD clinic at referral hospital where available this service so that clinical care will be provided based on the result of a laboratory test.
Generally, this service is included with out patient consultation service for men and in the gynecological examination, antenatal examination and birth spacing services at health centers where health staff had been trained on Syndromes-Based STD Clinical Management.
They should be a physician or a nurse providing outpatient consultation for men and providing gynecological examination, antenatal examination and birth spacing services for women at health center.
Service provider and patient should be same in gender so that shyness can be avoided and confidentiality can be kept.
Tasks of health center staff responsible for providing STD care-treatment service are as follows: - Be a disseminator to clients and community the prevention of STD article source, especially about correct and durable use of condom.
Make drug and medical-materials proposal and timely submit to OD office.
Sort of Drug Cefixime 200mg Doxycyline 100mg Erythromycin 250mg Metronidazole 250mg Clotrimazole 500mg Nystatine 200000UI Ciprofloxacin 500mg Cotrimoxazole 960mg Benzathine PN 2.
Members of the team may be varied from 3 to 5 people depending on scope of the work.
This team undertakes their task within coverage area of each health center.
Three options were recommended depending on participation of health centers and NGOs.
The roles 43 of health center staff responsible for voluntary confidential counseling and testing are as follows: - Voluntary confidential counseling and testing must be arranged in compliance with the guideline of the Ministry of Health; - Every HIV test must be provided with pre and post test counseling.
Procedures of HIV test must be complied with protocols of the Ministry of Health; - In case of test result is positive; a consequent supportive counseling is required.
Supportive counseling is essential to enable clients solve many circumstances.
For details, refer to Rules and Procedures for Implementation of Homebased Care and Community-based Care, and voluntary confidential counseling and testing of NCHADS 1-3-3 Tuberculosis A part of the health center staff work is responsible for control of TB in the area under management of the chief of health center.
Tasks of health center are as follows: 1.
An implementer and disseminator of guideline of the national program to the community 2.
Identify TB suspected case, collect sputum, transfer sputum cup or sputum slide to a place where laboratory test available 4.
Explain and refer severe case to referral hospital 5.
Responsible for provision of TB tablets to patients mobile DOTS and collect sputum of 2nd5th and 6th month, and then send to laboratory for a control test 6.
Timely and correctly register all TB patients to be treated 7.
Make monthly activity report and regularly submit to the OD office 8.
Make proposal of TB tablets and materials, and send to OD monthly 9.
Search for, explain and invite absent TB patients for treatment again 10.
Conduct DOTS supervision to community regularly 11.
Well collaborate with local authority, NOGs and community for better TB activity 12.
Participate in care for and advice to TB-AIDS patients 13.
Encourage and implement health education on TB Annex-14: TB Patient Referral Form and Annex-15: TB Treatment Card 44 1-3-4 Leprosy Health center staff in the whole country has the role to take responsibility for leprosy as follows: - Record every of suspected patient, refer and make writing notice to leprosy responsible person of OD - Provide information, education and communication IEC about leprosy - Participate in leprosy campaigns and research for new patients - Provide medicine to patients at health center and every 4 week provides medicine to patients who have no ability to visit to the health center.
Encourage patient to come for check this out medicine regularly.
Strategies: - Expand strategy, early diagnosis and treatment at health centers where provide full MPA.
For more information, read strategic plan 2006-2010 of the National Center for Malaria Control.
The patient must be transferred to the hospital where the Ministry of Health authorized for Avian Influenza care so that patient can be rescued on time following standard precautions for infectious diseases control and in compliance with guidelines of the Ministry of Health and WHO.
B- Definition Avian flue is caused by an influenza virus and causes of lower-part respiratory infection at bronchus and alveoli.
C- Transmission of virus Avian flu virus can rapidly spread inside of a human body.
It can be transmitted through direct touch with droplet, especially when touch sputum, mucus of chicken or birds while they are sick, coughing or sneezing.
In the other way, it can be transmitted through eating non-well cooked chicken or birds especially non-well cooked eggs.
Common clinical symptoms are: fever, coughing, breathless, throat pain or difficult breathing, and rare symptoms such as: abdominal pain, diarrhea.
D- Standard precautions Standard precautions include wearing surgical mask, gloves, eyeglass or facial protective veil when taking care of a patient with symptoms of coughing and panting to prevent scattered sputum or fluid.
Routinely wash hands with water and soap for 30 seconds before and after touching with patient, alcohol hand rub 70oC if water and soap is not available.
Note: never touch patient mentioned above without protective materials.
E- Community education Health center staff should understand about: - Mode of contamination and prevention of transmission at community: protect airway by closing nose-mouth when coughing-sneezing, wash hand with water and soap for 30 seconds or wash with alcohol if water and soap is not available, before and after touching the dead-sick chicken-birds and before and after cooking chicken-birds.
For more details, read National Strategy for Prevention and Control of Non-communicable Diseases 20072010 of MoH.
B- Service delivery - Provide basic mental health service 47 - - Accept continuum of care for mental patients transferred from referral hospitals or national hospitals Provide tablet or education Collaborate with local authority or all authority levels, NGOs, Village Health Support Group to conduct surveillance for severe mental patients who might cause accident to themselves or to others, so that they can be referred to referral hospital or national hospital Educate to community, mental patients and patient family about mental health Visit to treatment-abandoned patient and advise to return for treatment Well collaborate with relevant organizations to call for support and development of mental health service at community level.
C- Mental patients allowed for treatment at health center - Common anxiety - Depression - Chronic psychiatry - Non-convulsion alcohol abused - Epilepsy - Senile 1-4-5 Oral Health Oral health can be provided by health centers where available with dental nurse only.
Basic package of oral care to be provided by those health centers are: - Oral urgent treatment, traumatic restorative treatment and afford fluoride toothpaste through dental nurses at health centers.
A dental nurse can be a care provider and an educator to community people using dental kit, and an oral health educator to schoolchildren of schools located near health center.
Examples of minor surgery are: wound surgery, lard-removal surgery, etc.
Basic materials: - Sterile tambour or sterile cloth-box with a whole on its center - Box, sterile gauze - Box, instrument - Scalpel Handle - Kelly forceps 1 - Scissors, Operating - Scissors, Mayo Dissecting - Cup for disinfectant solution - Gloves sterile and non-sterile 1-4-7-2 Wound dressing Definition: Wound dressing is a package activity of wound treatment.
A table where the instruments place on it should be clean every interval of surgery or wound dressing for each patient Arrange instruments in a good order Use a sterile instrument kit for surgery or wound dressing, one kit for one patient at least Disinfection on and around incision or wound must be always started from a clean to an unclean area Wash with chloramines, scrub with brush and then sterilize again of the instruments used 1-5 Health Education and Health Promotion Services Health center staff has the role to provide health education at health center at outreach activity, and Village Health Support Group has the role to provide health education at community in accordance with manual for Village Health Support Group and Village Volunteers.
Health Education: dissemination of information relevant to diseases prevention and makes people accept new habit or new performance brought with health.
It is done to make people understand that, making themselves good health are significantly related to their behavior, meaning is that they should live in a proper way and good hygiene.
The main purposes of health education are: - To provide and upgrade new knowledge about health to people - To change behavior and performance, which may harm to health - To protect and prevent people from sickness that harm to their health.
To make people accept new ways of living with hygiene and safety, it is required to: - Upgrade knowledge: populations are educated with multi media on health so that necessary countermeasures for preventing them from diseases and harm to health are provided.
As well, health educator should specify strategies reflecting to the status and living environment of the population.
Health Education Techniques Heath educator should have proper technique, skill, experience and ability to provide an effective health education and response to the actual health problems of clients.
Therefore, health educator should be trained on basic knowledge such as health education technique, coordination, interpersonal communication, behavioral change, and use of health education materials, etc.
Health education can be done in 7 steps of education procedures during or after clinical care for clients.
Counseling technique is also used in this health education process.
Examples of health education are: education on diarrhea, dengue fever, malaria, tuberculosis, typhoid fever, other communicable diseases, wound care and neonatal cord care, etc.
GATHER technique is used for counseling with the following steps: - Greeting: greeting to each other - Asking: collecting the information - Telling: telling the information - Helping: helping for making decision - Explaining: showing and practice - Returning: Returning for service and return with a satisfaction 1-5-2 Health Promotion 1-5-2-1 Definition: Health promotion: a combination of health education, political and economical activities, and organization structure aims to facilitate for creation of environment and practice leading to health improvement or prevention.
Those programs include behavioral change in smoking or health, environmental health, food hygiene, primary health care and maternal and child health, etc.
Taken into actual implementation of these programs according to individual annual operational plan based on available human, material and financial resources are very essential and important to sustain the health promotion activities.
And, health center should play role as a secretariat and a technical coordinator for community health care works.
A regular meeting should be held to disseminate the information and exchange experiences in developing annul action plan, implementation plan and problems solving.
The members of the meeting are Commune Council, Health Center Management Committee, Village Health Support Group, Village Volunteer, Village Development Committee, NGOs and international organizations.
Chief of health center is responsible for technical coordination and chief of Commune Council is a chairman.
Health center should provide them all the health education materials such as: posters, leaflets and flipcharts, and they should be explained about simple method for use and dissemination of those materials.
Community Participation in Health Promotion Community participation leads people contribute to development of health service and other development activities at their community.
Community participation leads community to take responsibility, make decision and perform which something helps for health promotion, and enable people take care of their health by themselves.
The Ministry of Health supports the establishment of relation and management structure at community level such as: Commune Council, Health Center Management Committee, Village Health Support Group and Village Health Volunteer.
This structure is used to mobilize all groups of people in community to participate in health care activities and to strengthen linkage between communities and health center.
Health center plays an important role for management and coordination of health promotion activities at community.
Among those problems, maternal and child health status is the priority of the Ministry of Health.
Therefore, health center staff has the role to improve the maternal and child health by implementing the following 12 keys for family health: 1.
Complementary feeding for infant at 6 months and continued breath feeding until 2 years of age or beyond.
Feeding with sufficient micronutrient Vitamin A, Iron, Zinc, Iodine 4.
Complete immunizations to children within 1 year of age 6.
Children are prevented from malaria 7.
Children are ensured for good mental health and growth 8.
Continued or increased complementary feeding when children get sickness 9.
Correct treatment is provided to sick children 10.
Treatment for children should be followed physician instruction, children should be followed up and referred to hospital as required 12.
Pregnant women received proper antenatal care service.
Moreover, health centers must comply with clinical guidelines for referral hospital as well as guidelines for national programs concerning inpatient.
Annex-16: Health Center Discharge Form 2- Outreach Services 2-1 Guideline for Outreach Services A method to provide services at community level by health center staff to fulfill the services provided at health center so that all levels of people access to essential health services especially preventive services, and with no affect to the function of health center.
An essential service package for the near villages: where transport takes less than one hour by available means of the villages b.
Complementary service package for remote villages: where transport takes longer than one hour by available means of the villages 2-2-2 Frequency of Outreach Services a- It should be at least once a month in a village, it means that at least 12 times per year in a village.
All problems faced during outreach activity should be raised at the Health Center Management Committee meeting.
Chapter 4: Management and Support Services 1- Development of Action Plan, Budget Plan, Monitoring and Evaluation 1-1 Working Program 1-1-1 Working Program of the Personnel Chief of health center should collaborate with personnel to make 24 hours work.
And then, a monthly time table should be made with name of personnel, working day, duty time, outreach service and other works.
Example: in case of necessary, chief of health center rotates between staff of reception and staff of injection-wound dressing.
Staff rotation aims to: - Upgrade multi-skills of staffs - Motivate staffs - Avoid interval when a staff is vacant 1-1-3 Replacement of a vacant staff To avoid interruptive performance of the health center, chief of health center must make plan for replacement of a vacant staff by another staff based on: - Capacity - Workload and - Willingness to the work In this case, the delegation of work is essential.
In this case, chief of health center should help if it is huge lock poker deposit />Although the service is limited, it is a quality, effectively service and functioning 24 hours over 24 hours.
To enable regular personnel meeting with mutual understanding, achieving good result and avoiding incidental phenomenon or wasting time, chief should choose a proper opportunity or change the meeting program if possible.
The place where the health center locates in should be recorded clearly the number of population in that area, correctly categorize the number of men, women, children, adult, etc.
Since the growth of the population influences the services of health center, and on the other hand, to ensure the provision of effective service, health center should group and prioritize them so that it is easy for interventions.
Example: - How many pregnant women have received immunizations?
Group of people with other problems which care requires for them.
Various microorganisms can be transmitted from one person to another directly by hands or indirectly such as by things, used instruments or linen and through air coughing or sneezing or through transmitting agents flies, parasite.
Indirect contamination happens more frequently than others.
Standard There must be a working system organized to reduce the risk of infection to both patients and staffs.
This working system becomes a part of infection control program in the health center.
All things which are touched directly by a patient even known and unknown infectious should be considered that they may cause infection.
Important Measures Separation of transmission sources from other sections of the health centers, if possible, including isolation of patients and those who contacted with patients should be done in case of serious contamination.
Stopping of transmitting ways by destroying used things and materials which are not reusable, and properly cleansing, sterilizing or disinfecting things which are reusable before using them again for more information, read Guideline for Hospital Infection Control.
The major purpose of this cleaning is to destroy mechanical power of visible dirtiness by pouring water on the dirty places and diluting them until dirty spots cannot be seen and then pouring away the cleansing water.
Soap and soap powder can help the delusion of bacteria and other microorganism.
Therefore, cleansing has strong effect on microorganisms.
Dilution and getting rid of dirtiness can destroy sources for breeding of bacteria and fungus as well.
Soap and soap powder has low chemical activity against microorganisms so cleaning cannot get rid of microorganisms more than 90%.
Negligent or rough cleaning not only has no effectiveness but has negative impact because it makes the microorganism spread over things and create more opportunity to infect other things as well.
Therefore, cleaning should be properly according to the standard.
The effectiveness of disinfection and sterilization depends on cleaning proceeded.
Principle of Disinfection Disinfection is an important part of hygiene practice in the health center.
There are various disinfectants and they are different in effectiveness.
The more effective disinfectants, the more poisonous they are.
Using disinfectant solution can be reasonable if there is a good balance between its action and poison.
The Principle of Sterilization In combination with good cleaning and sterilization is more effective in destroying microorganisms.
Sterilization is not completely secured.
It can kill over 99% of microorganisms.
To reduce level of infection by used materials, sterilization should be made for used materials which have been already cleansed the dirtiness is invisible.
Sterilization can be done by physical or chemical means: physical mean is based on heating using humid or dry Autoclaveor drying in sunlight or filtration.
By chemical mean includes: sterilization by using oxidized ethylene or other gases, dipping materials into antiseptic solution or sterilizing equipment for example glutaraldehyde solution.
Safety of Hygiene Practice in Medical Process Health center should have a clear policy and open information about safety in carrying out the works, which include at least: a- Using gloves, face-masks and uniform appropriately to procedures relating to liquid substance for cleansing king neptunes casino no deposit bonus and contaminated things.
Burning wastes Health care services inevitably produce a lot of wastes and those wastes can create risks to the health.
All the wastes resulted from activities of health facilities contain more potential infection and injury risk than other wastes.
Therefore, safe and reliable means for wastes management is very important.
Incomplete and inadequate waste management can cause serious consequences to public health and greatly affect to the surrounding environment.
Burning of wastes in incinerator is the best option for destroying the wastes.
The referral hospitals must have a well-functioning incinerator, which locates in a bid far from patient wards and kitchens.
And, the incinerator should be included in the maintenance program.
Keeping hygiene in health center At health center: inside of building, garden, flag-yard, well, fence, entrance and compound: a- In side of the health center building: should be cleaned daily, kept beauty, kept opened for good atmosphere and with light.
Avoid allowing mice, cockroaches, termites, spiders net and dust inside of it.
General waste condemned office materials, tree-leaves, grass and so on : - Office wastes such as condemned papers, plastic bags, clothes and other objects - For a health center where has a lot of trees, the fallen tree-leaves, the cutgrasses or the cut-tree-branches, must be burnt behind and far from the health center building.
The broken slides contaminating with germs, should be dipped in antiseptic solution.
The empty-vials should be put separately in a plastic bag for recycling.
The vaccine-vials should be dipped in antiseptic solution prior to recycling.
Safe disposal of wastes helps to: - Prevent the spread of infection to clinical click here who handle waste and to local community - Protect those who handle the wastes from getting injured accidentally.
An open wastes pile is dangerous!!
Bring the wastes of the health center to burn at a place where there is fence surrounded.
All the wastes should be burned or buried.
The wastes in the health center can be contaminated and non-contaminated.
These are the examples of non-contaminated wastes: kitchen waste, papermade boxes, plastic-made-containers have been used by the health center.
Contaminated wastes are the wastes bringing with microorganisms of risks and may cause infection to patients, health care workers and people in the community.
Here several examples about contaminated wastes: blood, pus, urine, stool and other body fluids as well as other objects containing with them such as the used bandage or syringes and needles.
All of the waste buckets should have lid.
These things can cause risks as well as epidemic of HIV and hepatitis B check this out />For more information, please read the Safety Injection Guideline.
Combustible wastes include papers, carton papers, kitchen waste and contaminated waste such as used gauzes and bandage.
The incombustible wastes include glass-made, metal-made and plastic-made objects.
Materials: a Plastic rubbish bins with lid b Thick gloves, broom, and shovel c Incinerator or enclosed container for burning Procedure: a- Collect wastes and put in bin that does not let fluid out.
click here will help to prevent injured.
A casters-equipped cart or big bucket with lid can be used for transporting the wastes to the burning or disposal site.
Purpose: to prevent injury and transmitting of HIV or Hepatitis-B virus infection to health care workers and the community The most common way in which health care workers are at risk to getting infected with HIV and Hepatitis-B Virus is through accidental injury with sticking sharp objects.
Examples: a bottom-mended-bucket, which might be made by thick plastic, cartons and metal using local raw materials such as tinned cans or thick carton boxes.
Neither breaks nor bend needles or other sharp objects prior to throwing away of them.
Put them into safety boxes after use.
Never recap needles after use please follow the Safety Injection Guideline.
Collect all sharp objects and put them in a safety box.
Put safety box at a place where it is used.
For examples: safety box should be put in the trolley while provide injection at health center, and bring along with while provide immunizations at communities.
When it is ¾-full, close the lid of the buckle to avoid spilling or falling down of syringes.
Wear the thick gloves while touching and transporting the wastes.
This will help to avoid getting injured.
Collect containers once a day generally or more frequently if necessary, and then bring it to the disposal site or to the provincial garbage collection place usually there is a big garbage collection truck from municipal, provincial or district town.
SiCim incinerator is the place where can safely incinerate sharp objects and incinerator at health center can incinerate ordinary wastes.
Wash hands after handling waste containers.
Examples: - A separate plastic bucket with lid without water leakage - Thick gloves - Broom and shovel - Solution hypochlorite 0.
A different in colors can be painted for contaminated wastes.
Example, red-painted plastic bucket is for contaminated wastes only.
Contaminated solid wastes should be incinerated at health center.
Purpose: King neptunes casino no deposit bonus prevent the spread of microorganisms from contaminated liquid waste to the staffs, patients, and the community.
Examples: - Autoclave or pressure cooker - Separate plastic bucket without any holes.
Procedure: a- Sterilize in Autoclave of all plates and test-tubes have been used to grow microorganisms.
Equipment: - Detergent - Clean water - Gloves 67 Procedure: a- Wear gloves b- Glass container: Rinse well with water, and then wash with soap powder and water, thus it can be used again.
It must be sure that these instruments cannot be used at community.
Plastic container have been used to store chemical are dangerous!
Don't reuse it for another purpose.
Incineration requires special instrument and bottle gas or other fuel sources.
Incineration is the best way to destroy the contaminated wastes.
However where incineration is not available, this should be executed using a large simple stoves.
Advantage of incineration and burning are as follows: - Microorganisms are destroyed by heat; - Large amount of wastes that require a lot of space are reduced to ashes.
Incinerate all wastes in special stove located in enclosed areas.
How to build and use a simple stove for burning wastes: a- Choose a place in a parallel direction of the wind inside health center, former district hospital or clinic.
Gather up wastes to be burnt and then put them in a waste bucket with lid.
When wastes are buried under the 68 ground, some demands were solved; meaning is that animals cannot scratch them.
The advantages of burying the wastes under the ground are as follows: - Avoid reuse of unburnable objects i.
HIV, hepatitis and tetanus.
How to Make and Use of a Waste-Burying-Site a.
Dig the hole at a specific location.
Bottom of the hole should be 6-feets over surface of water sources.
Wooden fence or a strong wall should be made using local equipments such as rock, concrete, wood, thorn-plants.
Excreta Disposal Systems Proper arrangement of human excreta is very essential since it can reduce diseases and can also keep source of water clean.
When flies, other insects and gnawing animals touch our stool, it definitely affects our health.
If no proper sewage system, epidemic of helminthiasis caused by contaminated soil would definitely occur.
Prevent the spread of diseases by proper disposable of human excreta.
Three important points of attention should be taken to keep good condition for our sewage system: 1 public sewers must be clean 2 communities use them correctly and 3 they must be properly maintained.
A suitable excreta disposal system should be: a- simple and easy for constructing using domestic materials b- easy for maintenance c- separated and free from climatic influence d- good in hygiene Communities should be trained how to use and well maintain of public latrines.
There are various systems, some system requires water and some does not.
A system applied with water is better than the one doesn't apply with water.
In this case, water must be 69 available all the times.
Contact local authority for further details about the figure and construction method, Hospital Services Department, World Health Organization Expert, or organizations concerned.
Points to be Remembered When a Public Latrine is Constructed 1.
Construct public latrine on a dry place and easy for draining out.
Build a public latrine downhill far from the well, which well-water is used for drinking.
The latrine should be at least 25 meters far from each well.
It should have at least one latrine for 10 patients.
Sufficient water and soap for hands washing and cleaning latrine should be available.
It should have separated facilities for men and women if possible.
Signs should be pasted inside of latrine so that users understand how to use.
Latrine cleaner should be provided with cleaning materials such as: waster tank, soap, brush, and disinfectants as well as a space for keeping those materials.
A good maintenance and operational system should be organized to keep latrine clean and in good working condition.
Clean water should be enough for: Health Center: 500 liters- 1500 liters a day for a health center.
One way to produce clean water for drinking, that is to boil water and keep boiling for 10 minutes at least.
In some areas wells were protected properly and located far away from source of microorganisms; and proper catching rainy water can also provide sufficient clean water and need no more sterilization.
Eau de Javel must be kept in dry and dark place free form air and rust, for example, in a plastic-made tank.
Procedure: 1- Choose a strong and easy maintenance hand pump and adoption to condition of that area.
Two types of pump are commonly used; pumping type is used in Cambodia.
A good idea is to call for support from MOH, UNICEF or WHO….
To supply sufficient water, it requires regular maintain of the well.
Well maintenance procedures should be well arranged.
Draining pipe Draining system can be a piping-drainage, an opened-drainage in row or without rowa subsoil drain, a vertical drain or a permeable pond.
It is important to have drainage system allows water flowing out and preventing the insects living in it.
Permeable pond or hole is a hollow piece of land filled up with stones and these holes should be dug surrounding a tap or a hand pump where is publicly used.
The wasted water is so dangerous, hence never touch it.
Health center staffs as well as other health worker use their occupational knowledge, skills and experiences toward enabling their services be actively and effectively functioned.
In this meaning, the manager of health center should be aware of what the quality is.
Therefore, to keep constant quality health care services at health center, manager should be able to manage time for staffs to receive continuous trainings according to their skill, and they also can be provided with newly additional technique.
In this meaning, the leader of health center can raise some questions relevant to the training: 1.
How were the training backgrounds of health center staffs?
Based on daily practice, do they apply their technique correctly?
Which points were they unclear?
And which points should they study more?
How training plan should be prepared?
This mechanism includes financial and non-financial motivation.
Health center should also encourage staff appraisal of their performance.
To link community and health center, the Village Health 72 Support Group was established.
The Village Health Support Group members are the volunteers who provide health service under the monitoring of health center staffs.
The group has at least 2 people for one village, one woman and one man, selected by election and according to selection criteria.
The tasks of the Village Health Support Group are: to disseminate all health messages to their community and attend the health-related meetings as a representative of the community and ensure to forward the information to all levels of people at community, facilitate communication between health center and community, support for the transparency and accountability of health center, promote the ownership of health center by community, support health center activities, assist in resources mobilization for sustainability of health center, be a feedback transmitter of problems and recommendations from communities to the Health Center.
So, what should be trained for Village Health Support Group?
According to the responsibilities of Village Health Support Group, this group should be trained on: a- Every of health education message b- Measures for Health Prevention c- Risk sings need to be referred or provided with first aid d- How to provide first aid e- Forms of report from community to health center f- Signs of sickness to be further followed up by health center g- Health services provided under coverage of health center and referral hospital h- Any health-related Prokas, regulation, instruction and so on i- Other services available in community that they need to communicate for health service j- Rights and responsibilities of client, and rights and obligation of health service provider.
Drug store has an important role to manage drug and medical materials, supply, record and ensure the sustainability of drug and medical materials in store in order to acquire sufficient drug and medical materials for effectively improving the treatment and care as well as health prevention.
To ensure the quality of drug and medical materials management, health centers should have: - A drug store manager and an assistant store manager - A drug store with appropriate size and location according to the standard of Ministry of Health available with shelves and crossbar pieces for storing drug and medical materials as described in the guideline.
Before signing for acceptance of drug and medical materials from OD store, it is necessary to verify the items and quantity in invoice.
Marks on any irregularities found on invoice and ask for signature by pharmacist from OD and OD director approval on the issues, and avoid deleting or correcting any figure has been already printed and singed.
After returning to health center, the issues must be reported to chief or vice-chief of HC.
Drug learn more here medical materials which were additionally bought by user fee casinos no free money real deposit other budget also need invoice and delivery notice with signature, following the same process to the ones received from OD.
In some cases, health center has the right to refuse irregular drug and medical materials such as: spoiled drug-medical materials, quantity differs from invoices, or any drug-medical materials which are new casino machines MPA level-unable to be used by the health center, etc.
In case of the difference in number, it must be thoroughly inspected and verified.
A committee should be organized to inspect all items and quantity of drug-medical materials received from drug store of operational district or other sources before they are kept in the store and supplied.
Expense for outreach services: to make easier in use of drugs for outreach services, the officer in-charge can borrow in advance the drug and medical materials with permission from the chief or vice-chief of health center, and then make the income-expense report of those drugs and medical materials to the drug store within the month not allow over 1 month.
Out of working time expense: a duty shelf or box should be prepared with specified item and quantity of drugs and medical materials necessary for patient treatment.
An appropriate list with name and quantity of those drugs and medical materials should be made with approval of the chief this number is not withdrew from the number of stock of drug and medical materials in the store.
Every time when use drug-medical materials, the consumption report or prescriptions must be sent to the store manager for compensation according to the item and quantity specified.
Store Manager and assistant must follow and use the sample forms as defined below: 1- Collection of daily consumption of drug and medical materials: tie or clip with prescription in each day by writing the date and number of prescriptions on the back of this document.
Annex-28: Daily report of drug-medical material consumption.
Annex28: Monthly report of drug-medical material consumption.
Annex-30: income-expense of drug-medical materials for outreach activities.
Store Card: routinely record in-out movement and provide information clearly about the stock quantity in the store after a-half month used, inside and outside of health center.
Annex-31: Store Card 4- Record of drug and medical materials: report the quantity of drug and medical materials received from all sourcesconsumption, latest balance of all items of drug and medical materials, and then calculates the proposal for next cycle of the health center.
Annex-32: Report of accumulated drug and medical materials.
Furthermore, the health center also has the obligation to supporting the technical unit of health post regarding drug management.
Annex-33: Drug-medical materials proposalhand over form.
In the same manner, supply of drug-medical materials from health center to duty shelf is done based on a list temporarily determined, but not allowed to withdraw from the drug store of the health center.
Note: All management documents should be kept for at least 5 years, except in a special case, which has a particular instruction.
To avoid out of stock, drug store of health center should make proposal for fulfillment of stock and submit to operational district at least 10 days before the monthly supply so that drug store of the operational district is able to monitor and supply on time and accurately.
Drug store of health center should try to constantly maintain a reserved or safety stock, and report or provide the information about consumption to operational district so that the stock can be controlled.
The safety or reserved stock is allowable for 1 month or at least 60% of stock to be released for monthly consumption.
The contents of MPA kit is defined according to necessary medical services shown in the MPA guideline.
Confirm the condition and sterilization before use.
Pay attention to secondary infection after use.
Do not leave used items where ordinary people access.
The operator should keep the instruction manual beside of the medical equipment if the equipment has it.
Sterilizer, vaccine refrigerator etc, The equipment, witch has a risk of explosion Sterilizer, absorption vaccine refrigerator, gas stove etc need to be inspected the safety condition every before use.
When the Health center uses electrical apparatus for example electric vaccine refrigerator, the stability of power supply needs to be examined.
If electricity is unstable or the power cut often happened, the refrigerator needs to equip the special power supply regulator for refrigerator.
It is recommended to install a fuel type absorption refrigerator in such area.
To avoid buying the low quality items, purchaser may consider adding some pre-conditions for example GMP certify, UN qualify, ISO, or country industrial standard etc, when procured.
Used medical equipment may bring some trouble and there is the risk of maintaining accuracy and safety as a medical devices.
When the equipment breaks, it may happen the spare parts could not be found in the market.
Inventory check and inspection of the items should be performed at least once a year.
Scale removal of sterilizer, cleaning of gas burner etc, 6 The operator should execute minimum safety inspection for particular equipment.
And try to allocate a budget for maintenance spare parts and repair cost of MPA kit in case if items need to be attended repair work.
Evaluation of poor patients For operational districts where had no pre-evaluation by the government through the Ministry of Planning, an evidence-based evaluation should be done when patients come for the service, using evaluation tools of the Ministry of Health.
Roles, tasks and responsibility of health center: - Make contract with project implementer of the community-base health insurance on the provision of health care service of minimum package of activities to the member of the community based health insurance - Mobilize people to participate as the member of community-base health insurance project - Provide the health care service of minimum package of activities to the insured people and their family members were listed in Cambodian Family Book.
For more details, refer to the Implementation Guideline for Communitybased Health Insurance Project 5- Referral System A Guide for Health Center Operational district should ensure that every health center has completed with following conditions to make successful referral system in own coverage areas.
The conditions include solution for third lateness-that is shortage of a proper care at the health facility.
It should have at least one skilled health personnel accompanying with patient in the ambulance.
All of health centers should have a patient allocation system.
The patients' condition must be controlled prior to refer.
All of health centers should have a common registration system to record every case referred to the referral hospital some health centers already exist a referral registration list, for both of out patients and pregnant women.
Every health center should have a functional communication system such as: communication radio connected to referral hospital or operational district.
A health center where electricity is permanently not available, there must have a battery.
A communication radio should be placed where it can be communicated all the times, even out of working time.
Health center should daily communicate with referral hospitals to check function of radio at referral hospital.
Communication radio must be set at a wave frequency agreed with operational district and it is never switched off.
Health center should communicate with referral hospital for every of referral case even though patient use a private transportation please read section 56 below about detail information to be provided to referral hospitalbefore a patient is referred.
If telephone service is available at the place or near the health center, it should have telephone numbers of referral hospital staffs, referral hospital itself, director of referral hospital or telephone number of staff who is assigned by the director as in-charge of ambulance health centeras well as the telephone number of ambulance drivers.
Referral hospitals should instruct all health centers whether who should be called in case of using the telephone service.
Private telephone numbers shouldn't be shown in public only telephones of referral hospitals should be shown to public.
Provision of referral services and qualities of care 10.
Staffs should understand when to refer a patient who requires nursing care service at referral hospital see the detail explanation in the clinical guideline for health center.
Staffs make their best to refer patients to the nearest hospitals.
All the health center staffs including the contracting staff and ambulance driver of health centers, if there is should be trained on first aid so that proper care and management of emergency case can be ensured before a patient is referred to the hospital.
Health Center staffs should provide enough information to patients about the situation of illness, provide counseling on importance of a referring and encourage the patients to follow referral procedures.
Emergency materials should be available all the time for staff who works at out of working time and for night duty staff.
Emergency kits must be ready for bringing with when a patient is referred annex- 34: referral kit.
Chief of health center and drug manager are responsible for fulfillment of the kit after each referral case.
Kit must be checked every time when OD conducts supervision to health center.
A patient can be referred to the referral hospital by: a.
Mode of health center if there is c.
Ambulance of the referral hospital 17.
Transportation mode depends on several factors such as: a.
Severity of the patient b.
Location, and possibilities- some villages can be accessible by vehicle, or even it is possible but takes time.
In this case it may wastes the valuable times to wait for ambulances from referral hospital to pick up the patient.
Many health centers are under the coverage area of a referral hospital; only one ambulance cannot pick up patients from different places at the same time, thus priority will be given to the emergency patient.
Transport fee should not be a referral barrier.
Health centers and referral hospitals should give exemption to a patient who has no ability to pay for transportation including the case that the patient died before paying or during referring.
Health center should refer patient properly and on time.
The health center in collaboration with HCMC and commune council should prepare in advance a private transportation upon availability at their level, thus they can use immediately when whey need.
Ambulance of the health center if there is for referral case 21.
An exemption system must exist to ensure that the poor patients can use the referral system as required.
Health center should use the user fee for transportation if required.
A health staff is required to accompany with a patient to the health center and to the referral hospital, for example, a midwife should assist woman during labor.
Emergency kits should be brought with during referring.
All documents should be filled in and handed over when arrive at the referral hospital.
The staff who accompanies with a patient should bring with a communication radio or a telephones that is necessary for additional consultation.
Record of referred cases 25.
Duplicated sets of this referral letter should be completely filled in.
One set is kept at the health center.
As mentioned above, every case referred from health center should be recorded in a list and reported monthly to the operational district using form HC1 28.
Referral letters of health center and the number of referred patients recorded in the referral registration book should be summed up at the end of the month.
Referral letters of the previous month must be brought with when attend monthly health center chief meeting to receive feedback from hospital if the feedback has not been received before the meeting and the presentation about correct referring.
Please read the Guideline for Referral System.
If discharge letter has been received, it should be kept with the referral letter.
At some operational districts, patient referred by a village volunteer can be done according to the standard since a specific program was established and supported by NGOs such as: traditional birth attendant is responsible for referring of pregnant women complications; Village Health Support Group or DOTS Watcher may refer TB suspected cases; Village Malaria Worker is responsible for referring of malaria suspected patients some volunteers have received incentive.
At some operational districts, volunteers fill in the referral cards.
Therefore, document of every case referred by volunteers to health center should be kept and collected monthly by health center.
The feedback should be provided to VHSG through monthly meeting and to other referral persons when health center provides outreach services.
At monthly meeting, a forum should be given to VHSG to inquire or receive advices about patients referring.
Summary about Referral System at Operational District Operational districts should ensure that their health facility is functioned and referral system is performed.
Operational districts should motivate and support the community participation in receiving of services from health facility.
However, it requires support from other institutions to educate the communities about the services provided and solve barriers to access to the health facilities.
Budget from donors can help the community-base referral fund, micro-credit system, and support or pay for transportation to communities where contracted.
Health Center Provide proper care service at the health center including 24-hour care service and referring to the hospital as required.
Community participation may greatly contribute increase possibility to receive services, development of health center activities and improvement of quality of services provided by health center staff.
Community participation is an important factor enabling health center well functioned.
Relevant information is disseminated from health center to community and from community to health center through representatives of communities in the Village Health Support Group and Health Center Management Committee.
And, health center also knows what problems they are faced to and what they need.
If people know that health center welcomes them, friendly staff, good services, appropriate cost, and know in advance how much they should pay, they will use services of the health center more frequently.
An exemption system for the poor people should be precisely explained to the community representatives.
Experiences in the implementing process of community participation in health sector at many provinces in Cambodia shows two aspects in communication between health center and community: 1st is co-management and 2nd is information exchange in which both of them are considered as key ideas in determining scope of work and in identifying a structure for community participation.
Another meaning is that they each should fulfill purposes for significant aspects of relevant participation from community in functioning of health center.
It should be remarked that there is a numerous community representatives in these two structures.
A health center, which covers more than one commune, the representative of a commune council the health center is located in is selected to be a chairman of the of Health Center Management Committee.
Health Center Management Committee should have at least 7 members in total 9 or 13 or 15 people according to the number of communes covered by the health center.
This number is the most proper for commission to decide: - Health center: 2 or 3 people a chief and midwife or a chief, a deputy chief and a midwifethe members of Health Center Management Committee must the odd number and midwife is involved.
Chief of health center must be the permanent vice-chairman of the Health Center Management Committee.
If the health center covers more than 1 commune, there must have a representative from each commune.
Representatives of Village Health Support Group: In case of health center covers one commune, there should have 2 women and 2 men 4 people.
In case of health center covers more than one communes, there should have one woman and one man as representatives from each commune 2 people per commune.
Those representatives must be elected.
Chairman of Health Center Management Committee has the roles to: - Chair the monthly meeting of the committee and make decision depending on majority of opinions of the meeting members in compliance with the national policy.
Vice-chairman of Commission of Health Center Management has king neptunes casino no deposit bonus roles to: - - Chair the monthly meeting of the committee and make decision depending on majority of opinions of the meeting member instead of chairman and then report to the chairman, in case of the chairman is vacant.
Prepare relevant documents, agenda, invite the members to join the monthly seems online casino usa no deposit opinion, and make minutes of the meeting.
Member of Health Center Management Committee has the roles to: - Attend the meeting as invited by the chairman or vice-chairman.
Arrange transportation for referred patients from village to the health center or to referral hospital.
Monitor and evaluate the quality of services provision at health center, the community, the Village Health Support Group and other volunteers.
The meeting minutes signed by a health center staff and approved by chairman of Health Center Management Committee should be: kept one set at health center, sent one set to Operational District and one set to Commune Office.
To enable Health Center Management Committee complete the roles, the health center and Village Health Support Group should: 1-2-4-1 Health center should carry out the following activities: - Organize annual review meeting results - Provide information to all stakeholders through monthly meeting of health center and commune to prepare for making plan.
The minutes must learn more here submitted to Commune Council and Operational District, and set kept at health center.
Motivate members of Health Center Management Committee by available means.
Meeting minutes with the signature of health center staff and approval of chairman of the Health Center Management Committee should be: kept one set at health center, and one set submitted to Operational District and one set submitted to Commune Office.
Provide health information to community on time.
Well cooperate with health center staffs when provide outreach services.
Urgently report to health center when outbreaks of epidemic diseases, disaster, etc.
Disseminate the services available at health center and then report to health center about the number of people attended.
Involve in refer of patients from community to health center or to referral hospital.
Fill in list of target population at villages.
Representative of Village Health Support Group regularly attends meeting as invited by chairman of Health Center Management Committee.
Provide community health report to the Health Center Management Committee and disseminate information from health center to community.
Attend Health Center Management Committee meeting and Village Health Support Group meeting at the health center.
Village Health Support Group disseminate health message the community on time.
Cooperate with the health center, Village Development Committee and other organizations to promote health sector and improve health status of community.
Work up on their ability and available time.
Chapter 6: Facility Infrastructure 1- Health Center 960 health centers were established under the permission of the Ministry of Health.
Most of these health centers already had location and building.
However, some of the buildings do not match to the standard since they were constructed by NGOs and other institutions within the past 50 years.
Among buildings which were not matched to the standard, some of them can be renovated to adapt the standard, but some need to be destroyed or leave for another purpose.
It means that each health center should assess own building condition, and then make a concrete plan.
Poor design of health center building with bad road condition can be an obstacle for women to come for delivery and postpartum care at health centers.
Thus, these two services should be also provided by a competent health staff through outreach activities.
Nevertheless, the mechanism documentation, follow up, and adequate quality control should be kept to ensure that those services provision are part of public sector service, but not an illicit private activity of a health center staff; and make sure that official payment of user fee has been implemented always.
It is also necessary for all health centers to paste the tariff on the wall of the veranda of the health center building.
An investigation on usability of existing health buildings is required and must be carried out.
Annex-35: Standard Health Center Design Health center should have adequate transportation means such as motorbike, boat, bicycle, etc.
All the rooms, especially Delivery Room of health center should be equipped with electrical system adequately and electricity source is provided such as by Solar Panel, electricity generator or government electricity supply or private electricity supply.
Attention and measures should be taken by health center for good managementmaintenance of buildings, medical equipments, transportations and furniture.
Chapter 7: Medical Equipment and Furniture 1- Health Center 1-1 Furniture List of furniture for health center No.
L 360 x W 290 x front H 110mm Hand Brush Same as Deposit for harrahs casino Pail Diaper Same as C14 Three section structure Head, Buttocks and Foot Material: Coated steel or stainless Delivery Bed, 3-Section Size approx.
L 2,000 x W 570 x H 150mm Fuel-heated pressure type Chamber volume: approx.
E2 LPG gas cylinder Volume: 15kg LPG Screw type outlet with closing vale Meets Cambodian industrial standard Cylinder safety tested or retested within 3 years LPG pressure reducing regulator Screw type connector fitted with gas cylinder item No.
E4 Meets Cambodian industrial standard Gas hose: Lenght:3m Reinforced with nylon mesh With 2 pieces of hose clamp Cylindrical sterilizer drum 100 3 3 3 1 1 1 real activity real activity real activity 1 2 2 2 2 3 G7 Water Filter G8 Calculator Size approx.
Diameter 240mm x Height 150mm 0.
E2 Purification of Drinking water Ceramic candle type Water drop through candle filter by natural gravity Stainless steel body with an outlet tap Upper tank with 2 candle filters, Lower tank is water storage Size :approx.
Names, signs, specifications 5.
Stethoscope binaural Tong depressor metal 14.
Sphymomanometer Aneroide 300mm Hg with adult cuff Spare cuff for sphygmomanometer, adult size velco strip Sphymomanometer Aneroide 300mm Hg with children cuff Spare cuff for sphygmomanometer child size Velcro strip ; Blades surgical N 22 disp.
Health post should be located in the remote area and functioning as lowest level in district health system.
Thus, it is the first meeting points of people and governmental health services in the low population density provinces.
Health post is not commune nursing center but it is a place where provides health services in remote areas.
Therefore, criteria must be strictly complied with when a health post is established.
In case, number of 103 - population is lower than this, other options should be considered such as: increasing outreach service activities and organizing health volunteers.
For example a health center with 10,000 people of coverage population may have several health posts in its responsible areas, thus resources for supporting health posts should be included.
Each king neptunes casino no deposit bonus post should not have more than 2 staffs.
If no building, try to seek for resources for construction of the building in accordance with standard design of the Ministry of Health.
Mongkul Borei Provincial Referral Hospital 2.
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Kampong Chhnang Kampong Chhnang Referral Hospital 2.
Kampong Tralach Kampong Tralach 1.
Kampong Speu Kampong Speu Referral Hospital 109 9- Thmor Pich 10- Anh Chreum 11- Sra Lorp 12- Tuol Snoul 13- Chhouk 14- Suong II 1- Phar Chhnang 2- Kampong Chhnang 3- Preh Kosamak 4- Prey Khmer 5- Cheung Kreav 6- Svay Chrum 7- Chrey Bak 8- Sre Thmey 9- Psa 10- Tro paing Chan 11- Pun Ley Boribo 12- Chnok Trou 13- Prey Kri 14- Peam Chhkok 15- Aphiwatt 16- Chiep 17- Taing Krasaing 18- Kraing Skear 19- Kampong Hao 20- Svay RumPear 21- Chror Nouk 22- Prolay Meas 1- Ponlay 2- Phsa 3- Tropiang Chan 4- Svay Chroum 5- Krangskor 6- Chnock Trou 7- Prorlay Meas 8- Pong Ro 1- Kg Tralach Leu 2- Sala Lek Pram 3- Ampil Teuk see more Tacheh 5- Seb 6- Loung Vek 7- Koh Thkeuv 8- Svay Chhouk 9- Svay 10- Kraing Lovear 11- Thlork Vean 1- Dom Kravan 2- Chbar Thom 3- Rokar Tep 4- Trapang Kong 5- Kraing Pneay 6- Rolang Sen 7- Samrong Sambo 8- Rolang Chok 9- Kraing Skous 10- Kaheng Ta Or 11- Kroch Meas 12- Vor Sar link Treng Trayung 14- Ta Lat 15- Samrong Romduol 16- Trapaing Kraloeung 17- Moha Sang 18- Krosang Chek 19- Phnomtoch Pang Lovear 1- Kro Sang Dosleung 1.
Pich Changvar 1- Kdol 2- Pich Chang Va 6 Kampong Thom 2.
Kong Pisey Kong Pisey 3.
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Kampong Thom Kampong Thom Referral Hospital 110 20- Prey Chum Pou Mean Ang 21- Roka Koh 22- Oral 1- Srang 2- Prey Nhiet 3- Pich Mony Teuklaork 4- Snam Krapeu 5- Sdok 6- Moha Russey 7- Prey Vihear 8- Chung Ruk 9- Veal Ang Popel 10- Preh Nipean 11- Rumpea Meanchey 12- Tuol Ampil 13- Po Angkrang 14- Barsedth Po Mreal 15- Kak Preah Khe 16- Tuol Sala Svau Cho Chep 17- Kat Phlouk Pheakdey 18- Phong 19- Nitean Chamroeun 1- Veing Preh Sre 2- Damnak Smach 3- Damnak Chan 4- Cheung Ros Samaki 5- Ksemksan Trach Torng 6- Dom Kvet 7- Monor Rung Roeung 8- Anluong Chrey 9- Amleing 1- Ti Po 2- Taing Krasaing 3- Prasat 4- Kg Thmor 5- Laok 6- Thnot Chum 7- Balaing 8- Chaung Daung 9- Kro Va 10- Chong Dong 11- Boeung 12- Chhouk Ksach 13- Baray 14- Treal 15- Sro Lau 16- Kreul 17- Taing Kok 18- Srah Ban Teay 19- Protong 1- Thbong Krapeu 2- Sra Yov 3- Prey Kuy 4- Damrey Chan Kla 5- Kampong Thom 6- Acha Leik 7- Kokos 8- Kampong Kor 9- Kok Ngoun 10- San Kor 11- Prey Praos 12- Kampong Svay 13- Chey 14- Damrey Slap 3.
Stong 7 8 Kampot Kandal 151617181920211- Stong 1.
Angkor Chey Angkor Chey 2.
Kampong Trach Kampong Trach 4.
Kampot Kampot Referral Hospital 1.
Ang Snoul 111 234567891012345678910123456789101112131415112345678910111234567891212- Sala Visay San Dan Chheu Teal Mean Chey Sam Bo Chhouk Taing KraSau Samdach Ou Kroyasakrea Dong Banteay Stong Sam Proch Cham Na Leu Cham Na Kraum Stong Masa Krang Trea Pro Lay Daem Dong Tani Ang Phnom Toch Pro Phnom Cham Pey Dan Kom Dambok Kpous Sam Rong Trapaing Sala Kaut Wat Ang Sat Pong Chouk Kraing Snay Mean King neptunes casino no deposit bonus Tro Meng Ba Neav Watt Pratheat Watt Koy Koh Sla Dang Toung Ang Romeas To Toung Tra Paing Raing Sre Cheng Chres Chum Pou Van Russey Srok Svay Tong Prek Kreus Beung Sala Kan Thor Lech Kampong Trach Damnak Kantout Sre Chea Touk Meas Sdach Kong Banteay Meas Thnot Chong Srang Kraing Ampil Treuy Koh Kampong Kandal Kon Sat Tra Paing Sangke Prey Khmum Chakrei Ting Kampong Kreng Koh Toch 10- Trapaing Lopov Bek Chan Kambol 2.
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Ta Khmao Provincial Referral Hospital 1.
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Sen Monorom Provincial Referral Hospital 113 891011121234567891011121314151234567123456712345678910123456789101112131415123456- Svay Pro Teal Treuy Sla Ta Lun Kporp Prasat Ta Khmao Prek Ho Prek Samrong Anlung Romiet Siem Reap Rolous Daum Rus Roleing Ken Beoung Kiang Tro Peing Veng Svay Rolum Sitbo Chheu Teal Prek Thmey Kampong Svay Smach Mean Chey Stung Veng Bak Khlang Neang Kok Trapeang Roun Koh Sdach Russey Chrum Boeung Preav Sre Ambel Thmar Sar Andong Teuk Chiphath Tak Kavith Keo Phos Cham Bok Ta Mao Prek Prosop Ksach Andet Pong Ro Chroy Thmor Kanhchor Dam Rey Phong Snoul Ksim Snoul Ksem Bos Leav Kantout Thmor Kre Thmey Rokar Kandal O Russey Chroy Ban Teay Saup San Dan Sambo O Kreang Svay Chres Tropiang Sre Sen Monorom Koh Nhek Pichda Or Raing Keo Sema Memang 1- Russey Chrum 2- Ta Tay 2 Koh Kapi 1- Stung Thom 2- Dounmeas 3- Sreneam 123456789- Doun Meas Sreroneam Beung Char Rolous Rum Puk Chang Krong Vattanak Kbal Damrey Mouyroypram 1234567- Pou Loung Phum Toul Ro Yor Sre Ampum Pou Chrey Krong Tehs Andong Kraleung 8910111213141516171812 Phnom Penh 1.
Chheung Phnom Penh Municipal Referral Hospital Samdach Ov Referral Hospital 2.
Kandal Chamkar Mon Referral Hospital 3.
Lech Pochentong Referral Hospital 4.
Tbong Mean Chey Referral Hospital 13 Preah Vihear 1.
Preah Vihear Prvincial Referral Hospital 14 Prey Veng 1.
Kam Chay Mear Kam Chey Mear 2.
Kampong Trabek Kampong Trabek 114 123412312345123451234567891011121- Kilometre 9 Chroy Changva Anlung Kangan Daun Penh Phsa Deum Thkove 7 Makara Toul Svay Prey Pong Teuk Samrong Krom Khmuonh Teuk Thla Tuol Kork Stung Mean Chey Chamkar Dong Niroth Prey Veng Chak Angre Chhep Saang Chrach Ro Vieng Phnom Dek Chhnuon Cham Roeun Kou Len Boribo Chom Ksan Sa Em Tbeng Meanchey 13- Yeang 1- Kok Kong Lech 2- Tnuot 3- Kanch Chreach 4- Preal 5- Cheach 6- Krabau 7- Kra Nhoung 8- Doun Keung 9- Smong Cheung 10- Smoung Thbong 11- Seang Kveang 1Ko Kchok 2Prasat 3Kansom Ok Dak Dam O Oum O Char Pou Trom Sre Ey Mou Yel Peam Chi Mat O Klor Kdoy Sre Chrey Sre Thom 1- Samaky 2- Kork Roka 3- Trapaing Anchanch 1- Anlung Korng 1- Kampong Sralau 2- Kunapheap 3- Putrea 4- Sre Veal 5- Doun Mar 6- Svay Damnak 7- Tnol Kuong 8- Sre 9- Ta Seng 10- Ta Pas 11- Sra Yang 12- Tnol Bek 13- Kdark 14- Pring Thom 15- Prasat 16- Kan Tuot 17- Kraing dong 18- Po 19- Kampong Pronak 3.
Neak Loeung Neak Loeung 5.
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Prey Veng Provincial Referral Hospital 115 45678910111234567891012345678910111213141516171234567891011121314151234567891.
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Chong Ampil 1- Boeung Khnar 2Snam Preah 3Trapaing chong 4Meteuk 5O Tapong 6Svay Daunkeo 7Khnar Totung 8Rumlech 9Boeungbotkandol 10- Talo 1Peal Nhek 2Koh Chum 3Prey Nhi 4Prek Thnot 5Wat Loung 6Wat Po 7Kandieng 8Sya 9Sre Sdok 10- Raing Til 11- Krakor 12- Kampong Luong 13- Chhoeu Tom 14- Boeung Kantout 15- Chhouk Meas 16- Ansa Chambok 17- Kravanh 18- Pro Ngil 19- Somrong 20- Ta Sah 21- Pra Moy 1- Ochum 2- Lumphat 3- Andong Meas 4- O Yadav 5- Borkeo 6- Voeun Sai 7- Banlung 8- Ta Veng 9- Ka Chon 10- Kaun Mum 12345678910- Kampong Thkov Sen Sok Rong Ko Sam bour Srey Snam Sleng Spean Prey Chrouk Chanleas Day Sra Nal Prey 1- Anlong Reap 2- Krapeu Pii 3- O Sam 4- Thmo Da 1234567891011121314151617- Poy Samaki Labaing 1 Seda Gnag Ta Lav Somthom Ya Tong Bor Kham Long Khung Kechong Koklak Hatpak Pakalan Sre Ang Kroag Serey Mongkol Teun 2.
Siem Reap Provincial Referral Hospital 3.
Soth Nikum Soth Nikum 4.
Angkor Chum Angkor Chum 18 Sihanouk Ville 1.
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Stung Treng Provincial Referral Hospital 117 1234567891011121314151612345678910111213141516171819123456789101112131415123456789101234567- Chreav Mondul I Kok Chok Siem Reap Sambour Po Mean Chey Chong Kneas Angkor Thom Peak Sneng Banteay Srey Preah Dak Rum Chek Kan Dek Prasat Bakong Mean Chey KanTreing Dam Dek Kachas Sam Rong Popel Chan Sor Dan Run Kean Sangke Kampong Kleing Svay Leu Kampong Kdey Spean Thnot Loveng Russey Kok Thlok Krom Anloung Samnor Sang Veuil Pong Ro Krom Khvao Kok Thlok Leu Russey Lok Doun Keo Puork Sosor Stom Reul Teuk Vel Somrong Yea Angkor Chum Cha Chuk Norkor Preas Kok Dong Bort Varin Svay Sar Damnak Slagn Krabey Real Stung Hav Teuk Laok Veal Rinh Andong Thmor O Oknha Heng O Chrov Ream Sangkat I Krong Sihanouk Cheung Ko Stung Treng Srah Russey Thala Bariwat Preah Romkel Chamcar Leu Siem Pang Kamphon 1- Koh Roung 2- Prek Kranh 123- Kbal Romeas Svay Rieng Chrob 20 21 Svay Rieng Takeo 1.
Chi Phu Chi Phu 2.
Romeas Hek Romeas Hek 3.
Svay Rieng Provincial Referral Hospital 1.
Ang Roka Ang Roka 2.
Don Keo Provincial Referral Hospital 118 8Sre Kor 9Sre Krasaing 10- Koh Preah 1Prey Ankunh 2Bavet 3Prey Kaki 4Mesa Thkak 5Samley 6Thnort 7Kset 8Porpet 1Kampong Trach 2Ang Prasre 3Dong 4Am Pil 5Krasaing 6Chrey Thom 7Mouk Da 8Mream 9Chantrey 1Svay Rieng 2Basack 3Chamlang 4Chek 5Svay Chrum 6Ta Suos 7Kruos 8Krol Kor 9Svay Yea 10- Daun Sar 11- Svay Thom 12- Svay Ang 13- Kandieng Reay 14- Sang Khor 15- Svay Rompea 16- Gnor 17- Sam Yong 18- Preah Ponlea 19- Thna Thuong 20- Chak 1Kus 2Tram Kak 3Trapaing Pring 4Ta Phem 5Ang Ta Som 6Prey Chour 7Prey Sbat 8Trapaing Andeuk 9Ang Roka Dong Chambok Kan Deung Tonle Bati Put sar Lompong Trapaing krasaing Kraing Leav Tram Khna Khvau Chumrah Pen Roveang Samrong 1Beung Tranh 2Lom Chang 3Trea 4Baray 5Rokar Khnong 1- Bos Phang 4.
Prey Kabass Prey Kabass 22 Odor Mean Chey 1.
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Article 2: Health center must continue to provide minimum package of activities including outreach service activities.
Article 3: Drug-medical equipment supply from OD store to health center must be complied with existing system MPA Kid through the referral hospital.
Article 4: Annual budget of health center made and allocated following the existing system through, but must be referral hospital.
Article 5: Health center must submit its reports to the operational district through the referral hospital.
Article 6: Any charter differs from this Prakas is annulled.
Hong Sun Huot C.
Village: ……… ………Commune: ………….
Hospital arrival date: ………………………………………………………………………….
Current history: Examination at arrival time: Vital signs: Body temperature: …….
Treatment when referring: Initial diagnosis Medicine given this time Reasons for refer: Signature ………………….
Sputum Test Form Health Center name …………………………………………………………………….
Operational District: ……………………………Municipality or province: ………………….
Name and sure name: ……………………………….
First time Second time Third time Fourth time Fifth time Name Age Client code No.
Date: ………………………………………………… Other problems regarding delivered: ………………………………………………………….
Time delivered placenta: ………….
Perineum: ……………………………………………………………………………………… Suture: ……………………………………………………………………………………….
Baby Sex ……… Weight ………….
Height ………Head perimeter………Chest perimeter……….
Communication Factor Heart rate Respiratory effort Color Muscle tone Color Deliver Apgar score 5 minutes after delivery 10 minutes after delivery Other problems of delivery: …………………………………………………………………….
Number of pregnancy: …………….
Deliver: ……… Admission number ………………… Admission date……………………… Admission time ……………………….
Rupture of membrane: ……………………………………….
Health center admission date Name Age Address Refer from Delivery code No.
Contraceptive method: …………………………… Type: …………………………………………….
Please come back for examination on : ………………………….
Even though your health condition is good, you should can slots with free bonus no deposit idea regularly according to appointment date of the birth spacing clinic.
Please bring this card a long with you.
BT patient record book No.
Date of refer: ………………………….
Signature Physician Seen and Approved Chief of Health Facility 135 Annex-15: TB Treatment Card Number king neptunes casino no deposit bonus TB Patient Registration:…………….
Number of TB Patient Book:…………………….
Full Name of Patient………………………………………….
Name and address of person who can be contacted:…………………………………………………………………………….
Supported by GFATM 136 30 31 2.
Tick - when we don't see patients taking pills and keep it blank when patients don't have pills.
Observation: Please record all necessary activities and dates such as constrain, follow up patient, solution, diagnosis of TB BK - and Non-pulmonary TB.
Operational District: …………………………Province: ……………… Date…………………….
Record the result of transferring patient into TB patient record book on sheet No.
Supported by GFATM 137 30 31 Annex 16: Health Center Discharge Form Kingdom of Cambodia Nation Religion King Provincial Health Department:…………… Operational District:…………………….
Health Center Discharge Form Name…………………………………….
Diagnosis at discharge time…………………………………………………………………….
Physician in charge 138 Annex 17: Report of HC1 on Outpatient Consultation Monthly Report Date: from 1st to the last day of the month.
Number of communes covered by Health Center:.
Population covered by Health Center.
Number of poor patients exempted from user fees:.
Quantities of Zoning Activities Zone A Zone B Zone C Male Female Total Total of new cases Total cases Zone A: Is the village where has health center located.
Zone B: Out side the village where has health center located but it is under the coverage of health center.
Zone C: Patients come from other responsible area.
In-patient Activities Former District Hospital 1.
Number of Illness and Deaths in the Former District Discharged 0-4 years 5-14 years 15-49 years 50 years Diagnosis Sick Dead Sick Dead Sick Dead Sick Dead Simple malaria Severe malaria Diarrhea Cholera Dysentery Respiratory infection Dengue fever Dengue Typhoid fever Non-Tubercular meningitis Measles Acute Flaccid Paralysis Diphtheria Pertussis Neonatal tetanus Other tetanus Tuberculosis AIDS Male STD Female STD Gynecology Delivery Road accident Mine accident High blood pressure Cardiopathy Diabetes Eyes diseases Marask, Kwashiorkor Substance abuse Other mental health Other Total 142 Total Sick Dead Annex-19: Report of HC1 on Laboratory Activities III.
Laboratory Activities for health center that have laboratory unit 1.
VDRL: Venereal Disease Research Laboratory; VCCT: Voluntary Counseling Confidential Testing 2.
Antenatal and post-partum cares, and delivery 1.
Antenatal examination and at risk pregnancy detection 1st Time 1 2nd Time 2 3rd Time 3 4th Time 4 5th Time 5 Total At risk 1+2+3+4+5+.
Post-partum cares 1st Time 1 2nd Time 2 3rd Time 3 Total 1+2+3+.
Folic acid and iron supplementation of pregnant women received iron tablet at HC 1st Time 60 tablets 2nd Time 30 tablets 3rd Time +.
Abortion and Induced abortion 6.
Birth Spacing People received program New client Pill Pack Injection Dose Condom Unit Intra Uterus Doppler Unit Total of clients of contraceptives used of new acceptors of drop-out clients of current users 147 Implant Total Other discussion Annex-22: Report of HC1 on Activities of Immunization Program VI.
Children under 1 year At Health Center Outreach 2.
Pregnant women Tetanol 2 Tetanol 1 of of women women Tetanol 3 of women Tetanol 4 of here Tetanol 5 of women 3.
Non-pregnant women aged 15-44 years Tetanol 4 Tetanol 3 Tetanol 2 Tetanol 1 of of of of women women women women Tetanol 5 of women At HC Outreach 4.
Other Activities and Comments Summarize key issues occurring in the operation of health center.
Describe other activities undertaken that are not in the report.
Chief of Health Center Signature Date:.
Reporter Signature 150 Annex-25: Report of HC1 on Zero Report Guidelines for Epidemic Disease Report 1.
Dengue fever poliomyelitis - Disease Case: Patients under 15 years old have high temperature from 38oC to - Children under 15 years old who have an acute flaccid paralysis 40oC and this heat is not easy to reduce by using decreased-heat medicines and immediately.
Jaundice stomach, or Lachtei sign In this case the - Disease case: Patients have got severe laboratory should have jaundice.
They have yellow eyes and Hemoconcentration over 20% compare skin and urine is dark yellow, not with normal value and the rate of hungry, exhausted, and the upper Plaquet dicrease Thrombophenie right of the abdomen is hard.
Diphtheria - Disease Case: We can recognize patient one family, the same village, one by havinglaryngitis or pharyngitis, or school, and an inpatient.
Measles - Disease Case: Person is age over 5 - Disease Case: In this case it has red years old, have temperature over irritated skin, fever and cough, running 38oC, cough or difficult to breathes, mucus or red eyes not Chicken pox or breathe quickly - Or children from 1 to 5 years old 9.
Encephalitis and Meningitis - Disease Case: The individuals who have have cough symptom or difficult to high temperature equivalent to 38 degree breathe and have breathe quickly Celsius or more or have one of these more than 40 per minute.
Neonatal Tetanus include in chronic lung disease such - Disease Case: Neonates normally can be as tuberculosis.
From 3 to 28 days 4.
Cholera mental disease meningitis likes the crazy dogs or like mute crazy dogs, they - Disease Case: In the region that will slowly become unconsciousness or we not sure it have cholera or not, death during 7 to 10 days after the patients over 5 years old have appearance of the first initial symptom severe dehydration or die cause cause by weakness of respirator.
Dysentery - Disease Case: Is person who used to have severe diarrhea and have stool with blood - Group Occurrence: There are 5 cases or over that related to the same time and place e.
Come from the same village, cause of using same water supply, or working together.
Weekly Emergency Report All orderly reports of communicable diseases surveillance system: Health Center, Referral Hospital, Operational District, and including Provincial Health Department must prepare weekly emergency report.
The weekly emergency report form must have the same content for all levels except provincial and operational district levels which need to be included the number of health centers, referral hospitals, and operational districts.
The weekly emergency report record information related to disease, syndrome and 12 new cases.
Furthermore, it also records the unidentified diseases that happen as a package during short and same time.
Chief of Health Center Date: …………………….
In case need to be reported immediately The selected diseases that seriously harmful people health was considered as epidemic disease which needs to be detected immediately and repeat response on time in order to avoid its threatening.
These diseases must be report as suspected disease without any confirmation from laboratory.
Weekly Report Diseases that regularly occur in community, purpose of follow-up of these diseases are to find out increasing of new cases in order to limit the disease spreading.
The increasing of disease can be found by only provincial levels through regular analysis of data which collected from other places to compare with previous data.
Example: District: X First week……….
Dead Report Dead report means every health center and referral hospital has to record the disease cases defined in the definition weekly even though it is zero case.
Before fill in dead report, it should be checked daily patient record book, whether is it match with the existing case definition?
Disease Case and Report of Infectious Disease Detection Detection group has to detect when the epidemic disease happen.
Even though it is suspected disease or communicable disease spread in community.
The information that needs to fill in it is similar to information of other disease and infectious disease.
In necessary circumstance, we also need additional information for separate diseases.
During spreading, we have to fill every disease case in the Infectious Disease Report Form with the collection of sample.
These documents need to be maintained by the detection group for inputting data or for referent document.
Specimen Collection Form needs to be filled in based on the remark with collected sample in order to make laboratory staffs can notify which samples is belong to which patient.
Therefore, the information about Epidemiology and symptom are related with laboratory result.
Patient Identification Case No.
Sex: Male Female 154 2.
Laboratory Collect sample 1……… Collection Date: ….
The Class of the Last Disease a.
Verified: By laboratory b.
Extracted from investigation: Date of last diagnosis….
By Clinical Symptom circle it …………………………….
Detection Official Name:……………… Position:…………… Signature…………………… Note: One form for one disease case 5.
However, sometimes it is fact.
Clear detection are including descriptive analytical collection, pick up hypothesis of source of virus and its infection.
Follow-up patient, contacted people and continue study 155 about the Epidemiology in necessary case.
All suspected case should report to responsible level for information and top leaders could also provide counseling and support regarding to the verification and countermeasure for prevention of disease.
When the traffic accident patient arrive health center and in case patient can be treated by health center, health center staff should fill in the following forms: - First step: Fill in interview information - Second step: Fill in all patient information except the box describe about diagnosis of disability - Third step: Fill in all information regarding accident 2.
Health center must submit this report form with report HC1 to Operational District office for sum up report, and then, send it to provincial-municipal health department.
When traffic accident patient arrive health center and health center need further refer patient to referral hospital, health center staff should fill in some points in the first step such as1-2-3-4-5-8-9-10-11-12-12-13 except description box and -14 if they have enough time before referring.
While referring patient, health center staffs have to attach these forms with patient.
No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Daily record of drug and Medical material consumption Date: …………………….
S 1liter water Sachet Paracetamol 100mg, Tab Paracetamol 500mg, Tab Paracetamol Syrup 60ml Phen.
Pencillin 250mg, Tab Promethazine 0.
A Progesterone+Oestradiol Microgynon Progesterone Overrette Condoms 10 Depot Medro Progest Ace+Syr+Ndle 11 Blister A+ M2 Blister A+ M3 Blister A+ M4 2 3 4 5 6 7 8 12 13 Strength Form 200+0.
Seen and Approved Health Center Director Date: ……………………… 200….
Provider Order person Signature Signature Note: Fill in two copies before borrowing: One for drug store and one for person bring along with drug when go to out reach services and for making report.
Overstock Report of Drug-Medical Material in Drug Stock From Date: …………….
No Code Description Strength Form Qty.
Overstock AMC Expiry Date Observation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Note: These overstock drugs and medical equipments were supplied by Operational District or by donors.
The staff must bring the kit along with them while referring patient to referral hospital.
Those staff should responsible for recording all materials used during referring patient and return it back to health center when come back.
Pharmacists should fill in additional material to the kit as soon as possible or within same day.

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I found and played at two casinos that offer free cash for creating a real account.
There is no purchase required.
Are there any others like this?
I have seen several free money offers like these.
Two that come to mind are the Colosseum Casino and the Grand Opry Casino.
Personally, I don't get too excited over these offers.
However, I have played at the two casinos I mentioned because they also had a deposit bonus in addition to the free money.
What other options are open to an online casino player if they are dissatisfied with an online casinos response to a problem?
My particular gripes are removal of a bonus for inactivity and requiring a copy of a credit card statement to cash out winnings.
There is not much you can do in the way of complaining to a higher authority.
Some of the better jurisdictions have a government body to oversee the online casinos.
However, if you ever bring a specific complaint to their attention, then they seem to either do nothing or side with the casino.
It is much more effective to raise a stink on Internet bulletin boards.
Even if it doesn't work, at least other players will be warned.
A promotion from an on-line casino lets the customer select various options.
The options range from a 10% bonus requiring wagering 2X the deposit, up to a 100% bonus requiring wagering 10X the deposit.
I would wager 10X for the 100% bonus.
If you make the bet size small enough you can still stay under a 5% chance of going broke.
I don't have the exact number, but if each bet were 1% of the total deposit, then I doubt the probability of going broke would be more than 5%, even betting ten times the bankroll.
How do online casinos work out their promotions?
What is the best sort of promotion to play, money bonus on sign-up or cash back on games?
I ask because I have just received a promotion offering 5% of total stake back on any one of five games keno, slots, sic-bo, video poker and roulette and wonder if it's worth playing.
There is no simple answer to which is better, a deposit king neptunes casino no deposit bonus or cash back based on total money bet.
You have to consider the percentages offered, the amount of play required, and the house edge of the games in question.
This 5% cash back promotion sounds great for any game with a house edge of less than five percent.
The house edge on the small and big bets in sic bo have a house edge of only 2.
Video poker may be even lower depending on the pay table.
I would be interested to know who is offering this.
Thank you for all the excellent information that you provide.
My question concerns your recent answer to the question about gambling for a living.
Specifically, making a living from internet casino bonuses.
Do you think that this is still possible?
Back in 2000, I made a good deal of money from Internet bonuses.
If I had worked on it full time, I probably could have quit my job.
However in 2001, I only made about see more grand all year from Internet bonuses.
The reason for that is the fact that casinos have gotten so stingy with their bonuses.
Many of them require a player to play a deposit five or more times before withdrawing.
Even with a 100k bankroll, it does not seem that this could work.
The days when it was easy to make good money gambling on the Internet are over.
I just received the e-mail bonus offer for Casino Grand Bay and downloaded their software.
I was not able to locate their bonus requirement information but according to bet2gamble.
Assuming this is correct it sounds like a decent offer.
However, it was also stated that Blackjack play does not qualify for the bonus requirement.
If only blackjack were excluded I would say craps.
Next I would consider video poker.
Casino Grand Bay is a Microgaming casino which offers Jacks or Better video poker.
Following the optimal strategy the return is 99.
If you use mywhich has a return of 99.
So I would go with that.
Had this been another casino with stingy video poker I would have played baccarat, always betting on the banker.
Most online casinos offer bonus offers but do not allow wagers on games like roulette, craps and baccarat to be part of the necessary wagering requirements.
I am wondering about the exact reason for this.
Are they trying to stop players playing games which offer close to even money options then?
It seems to me unfair to stop new players to a casino playing such popular games such as these after offering a bonus.
Also you answered a previous question about player abuse by saying you should play 100% more than the minimum requirement to cash out the bonus.
As I see it if the casino lays down the rules for minimum wagering then that is all that is required by the player and if he can wager 8x the bonus without losing it then he deserves to be able to cash it out without being labeled a player abuser!
Thanks for your time Wizard.
The reason they do this is that before they implemented this rule some players would bet equal amounts on red and black in roulette, or the pass and don't pass in craps.
This would allow them to earn a bonus without putting much money at risk.
So king neptunes casino no deposit bonus added this rule in an effort to keep these bonus players out.
Casino on Net does allow play on any game but reserves the right to refuse the bonus if the player bets on opposites, which I think is a more reasonable solution.
Unfortunately many Internet casinos owners don't think they have to abide by their own rules and make them and break them as they go.
Two years ago the Golden Palace rounded up all the players they considered to be not be giving enough free play and locked them out of their accounts.
I know this because I had one of the accounts.
After a lengthy audit they reopened some accounts but seized the funds of others and donated them to charity.
This was despite the fact that the players followed every rule.
It just goes to show that there is no credible regulation of Internet gambling and that appearances are very important.
That is why I advise players to not even look like they are only after a bonus and to provide plenty of extra play.
I read your review of casinos and want to try Club Dice.
Regarding the terms on their website, they mention bonus will be deduct from the account once you make the cash-in even you fulfill the wager requirement.
I wonder then what is the meaning of this bonus?
This is what is called a "sticky bonus" and is not confined to Internet casinos.
When I went to Germany I had to pay 20 Duetchmarks to get in.
However if purchased 100 Duetchmarks in chips they gave me a free 20 in sticky chips.
A sticky bonus or sticky chip is one that can never be cashed out.
However if you bet it and win the winnings are real money.
They way to get rid of sticky chips is to keep betting them until you king neptunes casino no deposit bonus them.
In the case of Internet casinos you will need to keep cashing out winnings and always leave the sticky bonus in your account, then go back and play again.
I have encountered an unusual kind of bonus at Aqua Online casinos.
What is your advice on how to maximize the value of this bonus?
My advice is to try to achieve a very large win or go bust trying.
The greater your winning more info is, up to a point, the greater your expected return.
It is paradoxical but the only way to realize the value of the bonus is to lose everything.
So you want a high probability of ruin.
In practical terms, does the casino make learn more here money on a bet with a high standard deviation, than a bet with here low standard deviation, even if the two bets have the same edge?
Basically, I figure the probability of player bankruptcy is higher with a higher standard deviation.
Assuming the player plays the same number of hands regardless of results then the casino would make the same amount of money either way, over the long run.
Yet if the player will quit early if he reaches a certain loss point then he will play less on average and consequently the casino will make less money.
It sounds paradoxical but if you quit playing when you go broke then you will lose more at a low volatility game, because there is a smaller chance of ruin and thus the house edge will grind you down longer.
So by increasing your probability of ruin your expected loss actually goes down.
So although player A has a much higher probability of ruin his expected loss is much less.
This lesson is especially applicable to Internet bonus playing.
If you get the bonus up front I recommend betting everything in one hand to start.
By sometimes going broke before completing the play requirement you expose yourself to the house edge less and thus save time and lose less playing over the long run.
The biggest red flag that a player is a bonus abuser is that he stops playing shortly after completing the terms of a bonus.
If you did get a bonus but gave the casino at least 50% more play than required then you should also be okay.
Anyone in the gambling business with any sense would see the big picture, that in the short run there will be some winners, losing days, and maybe even losing months, but in the long run the house edge will prevail and the casino will win.
If so what are the odds that I could get their welcome bonus again with their current software?
Yes, Kiss used to be a Boss casino.
I think the seller of blackjackwealth.
I told him that on your page I could get the same information, given in his "system", for free.
Furthermore the seller denies me a refund, which according to my experience is very rare among serious sellers, although he WOULD give me a refund, provided I show him some gaming log thus proving that I have lost money following his "guidelines".
He even mocks me in his emails, when I've been asking for refunds.
Is that a good system?
Is it worth the money?
Thank you for giving me the login to read this guide, but of course I can't repeat it here.
This product basically says to go from Internet casino to casino milking new player bonuses playing blackjack basic strategy.
The basic strategy chart was obviously stolen from my site.
There is some value in his list of bonus offers, which you don't have to pay for, but that is about it.
Milking Internet casinos for bonuses is a common knowledge advantage play.
Back in 2000 or earlier it was very lucrative but today it is a tough grind due to smaller bonuses and increased play requirements.
I don't have a blacklist for this type of thing but am thinking of adding one.
In general, the higher the winning goal the greater the expected value of the phantom bonus.
I have done the math and I know that the casino advantage is not in excess of king neptunes casino no deposit bonus bonus and that the player has an advantage up until he clears.
He kept going for a week.
I have never heard of this.
What are the chances?
It seems almost impossible, like winning the lottery.
What do you think?
If you make the big win then grind out required play more conservatively.
What do you consider bonus abuse?
Almost every online casino has conditions that are vague when it comes to bonus abuse, which makes me leery.
I went bust trying for a big hit, so they made another similar offer with the same results and have now made a third offer.
Should I be concerned?
The industry has added so many rules to bonuses that often it is like navigating a minefield to stay in compliance.
Break just one rule and not only can they take back the bonus but winnings as well.
As an example look at one of the most respected casinos in the industry,as discussed at.
They seized £8000 from a player for playing the wrong game, which was added to a list of excluded games the day before the player played.
I regret that king neptunes casino no deposit bonus has come to this but terms and conditions in the industry have become so complicated and change so frequently that as a general rule I advise recreational gamblers to not accept bonuses.
Only bonus hunters experienced at parsing the fine print should take the risk.
Ironically, these are the same gamblers the casinos are trying to protect themselves from, and are the only ones they are going to be left with if the true gamblers get scared off by the minefield.
So, yes, you should be concerned.
However that is also a good bonus.
I would read the rules very carefully.
Then be aggressive and go for a big win early or go bust trying.
Update May 31, 2006 : Within hours of the publication of this column I received a response from Micki representing Trident Entertainment Group, of which King Neptunes Casino is a part.
I originally incorrectly stated that the player played the bonus the same day as the rules were changed.
In fact the player played the following day, based on server time.
So I apologize for that misunderstanding.
In the interests of expressing both versions I present the following message from Micki.
I know you are ethical bonus deposit 10 uk casino no accurate and therefore find it strange that your information is incorrect.
This is a sign-up bonus, so who would we inform that we are changing any clauses.
The Terms and Conditions also state that they apply from the date the bonus is claimed.
She did not however register or deposit to play until April 1 9:36pm Server time.
It should also be noted that this player used her bonus money to play on the excluded game.
Had she not used Bonus money to play on the excluded game she would have been paid.
Never the less we still left her account with 400 in king neptunes casino no deposit bonus, so she could start again.
The funds are still there and still available to her.
I thought you should be ac casino bonus no deposit of the facts.
Regards Micki At sites like BoDog you get bonuses for each deposit.
Once I make a deposit, and play enough time to be able to withdraw it, is it proper etiquette to withdraw the entire balance and shortly thereafter re-deposit the money to earn another bonus?
Reload bonuses are intended for players who blew everything the last deposit, although this usually is not a direct requirement.
To avoid suspicion it looks good to completely withdraw and allow time until the next deposit, the more time the better.
I would suggest at least a couple months.
There were no restricted games and the play requirement was the amount of the bonus only.
That came to aunfortunately.
However, after some discussion on my forum, I think that the award has to go to the Casino on Net single-zero roulette promotion, in which they paid 70 to 1 for bets on 0 and 7.
That has a player advantage of 92%!
This question was raised and discussed in the forum of my companion site.
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