II. Clinic Indicators 1. Health Facility Staff Average Average # Average time Number and Task/Service Male Fem clinical of patients (minutes) spent type of provided hours/day seen/day with patient GPs/Family Doctors Nurses Midwives Social Worker Psychologist Mental Health Nurse Psychiatrist CHWs Other: Notes and Recommendations: 2. Basic Pharmacy Data Availability in the PHC clinic or nearby Medication (please circle available) pharmacy in the previous week Generic antidepressant medication (amitriptyline, Never/rarely Sometimes ⓪ ① ② fluoxetine) Usually/always Never/rarely Sometimes ⓪ ① ② Generic anti-anxiety medication (diazepam) Usually/always Generic anti-psychotic medication (haloperidol tab Never/rarely Sometimes ⓪ ① ② and inj, chlorpromazine, Thioridazine) Usually/always Generic anti-epileptic medication (phenobarbital Never/rarely Sometimes ⓪ ① ② carbamazepine, diazepam inj, valproic acid) Usually/always Generic bipolar disorder medication (valproic acid, Never/rarely Sometimes ⓪ ① ② carbamazepine) Usually/always Medication as part of substance use programs Sometimes ⓪ ① ② (nicotine replacement therapy) Usually/always Generic antiparkinsonian medicine for the Never/rarely Sometimes ⓪ ① ② management of side effects from antipsychotic Usually/always medication (biperiden) 2. Average Score ( ) (= sum of all scored items divided by total # of items scored) Notes and Recommendations: 3. Basic Laboratory Services Availability Do have laboratory service in your health center? No Yes ⓪ ②
II. Clinic Indicators 1. Health Facility Staff Number and type of Male Fem Average clinical hours/day Average # of patients seen/day Average time (minutes) spent with patient Task/Service provided GPs/Family Doctors Nurses Midwives Social Worker Psychologist Mental Health Nurse Psychiatrist CHWs Other: Notes and Recommendations: 2. Basic Pharmacy Data Medication (please circle available) Availability in the PHC clinic or nearby pharmacy in the previous week Generic antidepressant medication (amitriptyline, fluoxetine) ⓪ Never/rarely ① Sometimes ② Usually/always Generic anti-anxiety medication (diazepam) ⓪ Never/rarely ① Sometimes ② Usually/always Generic anti-psychotic medication (haloperidol tab and inj, chlorpromazine, Thioridazine) ⓪ Never/rarely ① Sometimes ② Usually/always Generic anti-epileptic medication (phenobarbital carbamazepine, diazepam inj, valproic acid) ⓪ Never/rarely ① Sometimes ② Usually/always Generic bipolar disorder medication (valproic acid, carbamazepine) ⓪ Never/rarely ① Sometimes ② Usually/always Medication as part of substance use programs (nicotine replacement therapy) ⓪ ① Sometimes ② Usually/always Generic antiparkinsonian medicine for the management of side effects from antipsychotic medication (biperiden) ⓪ Never/rarely ① Sometimes ② Usually/always 2. Average Score (= sum of all scored items divided by total # of items scored) ( ) Notes and Recommendations: 3. Basic Laboratory Services Availability Do have laboratory service in your health center? ⓪ No ② Yes
IMC%202017%20PHC%20MH%20Integration%20Checklist%20Sample_designed.docx