Condition: This PMSMA Visit is applicable for all Pregnant Women whose ANC 1 is done

S No

Name of Data Field

Field Type

Value/ Options

Validation/ Logic/ Condition

Details of Pregnant women

 

 

 

 

1

MCTS Number/RCH Number (if Registration Number is not available)

Textbox

 

Auto populate 'RCH Number' form PW record

2

Does the beneficiary have an MCP card?

Radio button

Select:

  • Yes
  • No

 

 

If No is selected, MCP card is given

Radio button

Select:

  • Yes
  • No

3

Husband's Name

Textbox

Non-Mandatory
  • Accept alphabets only
  • Character limit 50
  • All letter should be in caps

4

Address

Textbox

Non-Mandatory
  • Accept numeric value, alphabets and special characters
  • Character limit 100

5

Mobile number

Textbox

Auto populate from 'Beneficiary Registration'
  • Accept numeric (integer) value only
  • Accept 10 digits only
  • Should not start from zero
  • Should start with digit 7, 8 or 9
  • All digits should not be same

6

Write the number of ANC's done before delivery

Textbox

Non-Mandatory
  • Auto-Populate

 

Status of the Mother

 

 

 

7

Weight (Kg)

Textbox

Non-Mandatory

  • Accept numbers only
  • Values from 30 to 200
  • Character limit 3

 

HRP Case, please visit the nearest HWC or call 104

 

 

 

8

Systolic Blood Pressure

Textbox

 
  • Accept numbers only
  • Character limit 3

9

Diastolic Blood Pressure

Textbox

 

 

10

Abdominal Check-up (Gestational Age in weeks)

Textbox

 

Calculate the difference between "Date of ANC" and "LMP Date" and display information in weeks

 

Fetal Status

 

 

 

11

Fetal heart rate per minute

Textbox

 

 

12

Twins pregnancy

Radio Button

Radio button:

  • Yes
  • No

 

 

Investigations

 

 

 

13

Urine Albumin

Textbox

 

 

14

Hemoglobin

Textbox

 

 

15

HIV

Textbox

 

 

16

VDRL

Textbox

 

 

17

HBSG (Hepatitis B)

Textbox

 

 

18

Malaria

Textbox

 

 

19

Was the HIV test done during ANC Checkup?

Radio Button

Radio button:

  • Yes
  • No

 

20

Swollen condition

Radio Button

Radio button:

  • Yes
  • No

 

 

 

 

 

 

21

Blood sugar test

Radio Button

Radio button:

  • Yes
  • No

 

22

Ultrasound

Radio Button

Radio button:

  • Yes
  • No

 

 

Intervention Details

 

 

 

23

Iron Folic Acid

Radio Button

Radio button:

  • Yes
  • No

 

24

Calcium supplementation

Radio Button

Radio button:

  • Yes
  • No

 

 

Tetanus Toxoid

Spinner
  • First
  • Second
  • Booster

 

 

LMP

 

 

 

25

Last Menstrual Period

Calendar

 
  • Last Menstrual Period (LMP)
  • Auto populate form PW record

26

Expected Date of Delivery

Textbox

Is Mandatory
  • Expected Date of Delivery (EDD)
  • Auto populate form PW record

 

Identification of high-risk factors

 

 

 

27

Identification of high-risk symbols

Radio Button

Radio button:

  • Yes
  • No

If yes, select the reason given below

28

If yes, select reason given below and write

Textbox

 

 

29

Pregnant in high risk category treated

Radio Button

Radio button:

  • Yes
  • No

 

30

Pregnant in high risk category was referred

Radio Button

Radio button:

  • Yes
  • No

 

 

Advice

 

 

 

31

Preparation for birth and complications, nutrition and family planning

Radio Button

Radio button:

  • Yes
  • No

 

32

Signature of Medical Officer in charge

Textbox

 

 

33

Save

Button

 

Check all validation and Mandatory fields



  • No labels