hstp ii hmis tools hospital, heath center and

HSTP II HMIS TOOLSHOSPITAL, HEATH CENTER AND HEALTH POST

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Pastoralist Registers, CHIS register, card and Tally sheets

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TB and leprosy Registers

RMNCH Registers and Tally sheets

NTD

NCD Registers and Tally sheets

MSD Registers & Tally sheets

Malaria Register

HSS

HIV Registers & Tally sheets

Health center and Hospital HMIS Tools

Contents

Health center and Hospital HMIS Tools

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HIV Registers & Tally sheetsContent / Home

Region Zone/Subcity/Woreda Health Facility Name Begin Date End Date

Health Centre /Clinic/Hospital ART Register

SN Datum CommentsRegistration

1 ART Start Date (DD/ MM/YY) Write the date patient started ART, written as (EC) Day /Month / Year (DD/ MM/YY)

2 Unique ART Number

Write ART unique number and it should be assigned when the client start ART.UniqueARTnumberassignedas:-Regionnumber/facilitytypecode/specificfacilitycode/ patient/client assignednum-ber.Region number: the following code numbers are used:

Tigray:- 01 SNNPR:- 07Afar:- 02 Gambella:- 12Amhara:- 03 Harar:- 13Oromia:- 04 Addis Ababa :-14Somali:- 05 DireDawa:- 15 Sidama:-16

Benishangul Gummuz :-06 South West Ethiopia=17 Facility type code: Hospital =08 Health Center = 09

Specific facility code:EachHC/hospitalintheregionsiscodedwiththreedigitsstartingfrom001.Thesespecificfacility codesareassumedtobe-givenbyregionstogetherwithfederal,whichmeansitispre-codedandgiven to each facilitycentrally.Patient assignednumber:

Aunique5-digitnumberwithinthefacility;thefirstpatienttostartARTintheclinicwillbegiven 00001 Example Unique ART No.01/08/001/00001

3 Medical Record Number (MRN) Write unique individual identifier used on medical information folder.

4 Name / father, grandfather name Write the patient’s first name in the upper space and father’s and grandfather name in the lower space

5 AgeIfthepatientislessthan5yearsofage,enterthepatient’sageinmonths-MMForexample,a4- month-oldchildisentere-das04M.Ifthepatientis5yearsofageorolder,enterthepatient’sagein years -YY. For example, a 6-year-old child is entered as06.

6 Sex(M/F) Write sex M= Male or F= Female

7 Address: Write Patient Woreda on the upper row and the patient, Kebele, House Number in the lower row

Status at start ART

8 Functional Status* Write the patient’s functional status at start of ART. A=Ambulatory; B=Bedridden; W=Working

9 Weight Write patient’s weight in kilograms.10 Height/Length Write height/length in cm at the start of ART.11 MUAC Write mid upper arm circumference in cm12 BMI /Weight for age Write the body mass index(BMI) for Adult /weight for age for Child

13 Nutrition Screening result/ Food Rx provided Write1=Normal,2=Mild,3=ModerateMalnutrition,4=SeverMalnutrition5=Overweighton theupperrowand-Tickonthelowerrowiftherapeuticorsupplementaryfeedingisprovided.

14 WHO Clinical stage Write patient’s WHO Clinical Stage at the start of ART15 CD4 (if child CD4 %) Write patient’s CD4 count (or CD4% for children) at the start of ART

CxCa screening and Treatment

16 Type of cervicalca screening (VIA, HPV) Write the type of cervical screening done as VIA or HPV

17 CxCa screening result

Type of Cx Ca Screening result (0- 6): 0. Cx Ca screening not done 1. HPV Negative 2. HPV Positive 3. VIA Negative 4. VIA Positive: eligible for Cryo 5. VIA Positive: Non-Eligible for Cryo 6. Suspicious for Cx Ca

18 Treatment of CxCa

Management of cervical lesions (0-5) 0. No treatment / further evaluation & management service given 1. Cryotherapy 2.Thermal ablation treatment 3.LEEP service 4. Further evaluation & management service given to Suspicious for Cx Ca 5.Referred

19 Referal service for women with Cx lesion (write code)

Referal for Cx Ca screening & management 0. Not refered 1. Refered for Cx Ca screening 2.Refered for Cryotherapy/ Thermal ablation treatment 3.Refered for LEEP srvice 4. Further evaluation & managment suspicious cases of Cx Ca

TB / HIV Co-infection

INSTRUCTION HOW TO COMPLETE ART REGISTERThe register is kept in ART room, and completed by the ART provider.

Information to be completed at front of register

20 Screened for TB (√)/screening result (P/N)On the upper row: Tick (Ö) if the patient is screened for TBOn the lower row, write P if the screening result is positive, N if the screening result is negative

21 XpertMTB/RIF(Gene-x-pert)/Urine LF_LAM sent(√)/Result(P/N)

On the upper row: Tick (Ö) if Xpert MTB/RIF/Urine LF_LAM sent to diagnose activeTBOn the lower row,write “P” if theXpertMTB/RIF / Urine LF_LAM result positive,”N” if the XpertMTB/RIF result negative

22 TB treatment Start date/ Complete date (DD/MM/YY)

On the upper row: write TB treatment start dateOn the lower row:writeTB treatment completion date (EC)Day/Month/Year (DD/MM/YY)

23-28 6H/3H/3HRP Prophylaxis (DD /MM/YY) Write the date as (EC) Day / Month /Year (DD/MM/YY) If the patient is taking 6H (INH) monthly or 3HP monthly (e.g. 6H-Date / 3HP-Date)

29 TPT completion write Y if TPT is completed; write N if not completed Fill when applicable

30 Fluconazole preventive therapy (FPT) (√) Tick if client is taking fluconazole preventive therapy

31

Enrolled to DSD Model (DD/MM/YY) (Up-per Space) Write date patient enrolled into DSD Model, written as (EC) Day/ Month/ Year (DD/ MM/YY)

Type of DSD (lower space) Write type of DSD: 1. 3MMD, 2. ASM(6MMD), 3. FTAR, 4. CAG, 5. PCAD. 6. DSD for Adolescent, 7. DSD for KP , 8. DSD for MCH , 9. DSD for AHD 10. Others

32 CTX Start date /Stop date (DD/ MM/YY) Write cotrimoxazole start date on the upper row and on the lower row cotrimoxazole stop date , as (EC) Day/ Month/ Year (DD/MM/YY)

33 Using any Modern Contraceptive(write code) 1. OCP, 2. injectables, 3. Implant, 4. IUD, 5. others

34Date Referred to PMTCT (DD/MM/YY) If the patient is pregnant, enter the Date Referred to PMTCT service on the upper row and date/Date Returned (DD/MM/YY) returned from PMTCT on the lower rowFirst line regimen

35 Original Regimen

Write the code for the first line regimen that patient has started. This is found at the bottom of the ART register.Adult 1st line regimens:1d = AZT - 3TC - EFV 1e = TDF - 3TC - EFV 1g = ABC + 3TC + EFV 1j = TDF + 3TC + DTG 1K = AZT + 3TC + DTG 1i = Other specifyChild 1st line regimen 4d = AZT+3TC+EFV 4e = TDF+3TC+EFV 4f = AZT +3TC + LPV/r 4g = ABC + 3TC + LPV/r 4i = TDF + 3TC + DTG 4j = ABC + 3TC + DTG 4K = AZT + 3TC + DTG 4L = ABC + 3TC + EFV 4h = Other specify

36 Substitutions: 1st code/ Reason/ (DD/MM/YY) 2nd code/Reason/(DD/ MM/YY

If the adult/child patient is receiving other first line regimen specify the regimens

If there is a1stsubstitution within the1stline regimen,write in the code for the1stsubstitute regimen, the reason code,and the date,written as (EC) Day/Month/Year (DD/MM/YY).

If there is a 2nd substitution, transfer this information to the bottom line and write in the code of the 2nd substitute regimen, the reason code, and the date, written as (EC)Day/Month/Year (DD/MM/YY) If Reasons for regimen change:1=Toxicity/side effects, 2=Pregnancy, 3=Risk of pregnancy, 4=Due to new TB, 5=New drug available, 6= Drug out of stock & if Other reasonspecify.

Second line regimen

37 Regimen

If the patient has been switched to a 2nd line regimen, write in the code for this regimen. Adult 2nd line regi-mens:2e= AZT +3TC +LPV/r 2f =AZT+3TC +ATV/r 2g=TDF + 3TC+-LPV/r 2h= TDF + 3TC + ATV/r 2i= ABC + 3TC+ LPV/r 2j = TDF + 3TC + DTG 2k = AZT + 3TC + DTG 2l= Other specify

Child 2nd line regimen:

5e=ABC+3TC+LPV/r 5f=AZT + 3TC + LPV/r 5g=TDF + 3TC + EFV 5h=ABC + 3TC + EFV 5i= TDF + 3TC+LPV/r 5m= ABC+3TC+DTG 5n= AZT+3TC+DTG 5o= TDF + 3TC + DTG 5j= Other specify

If the adult/child patient is receiving other second line regimen specify the regimens

38 Switches:1stcode/Reason/(DD/MM/YY) 2nd-

code/Reason/(DD/MM/YY

If there is a switch within the 2nd line regimen, write in the code for the switch regimen, the reason code, and the date, written as (EC)Day/Month/Year (DD/MM/YY).If there is a 2nd switch, write in the code for the switch regimen, the reason code, and the date, written as (EC) Day/Month/Year (DD/MM/YY) Reasons switch to 2nd line regimen:

8. Clinical treatment failure9. Immunologic failure10. Virologic failure

Third line

39 Regimen

If the patient has been switched to a 3rd line regimen, write in the code of this regimen. Adult 3rd line regi-mens:3a = DRV/r+DTG+AZT+3TC 3b = DRV/r+DTG+TDF+3TC 3c=DRV/r+ABC+3TC+DTG 3e= DRV/r+TDF+3TC+EFV 3f= DRV/r+AZT+3TC +EFV 3d = Other specifyCHILD THIRD LINE:

6c= DRV/r + DTG + AZT +3TC 6d = DRV/r + DTG +TDF+3TC 6f = DRV/r+DTG+ABC+3TC 6g= DRV/r +ABC+3TC+ EFV 6h= DRV/r +AZT+3TC+EFV 6e = Other specify

If the adult/child patient is receiving other third line regimen specify the regimens

40 Switches:1stcode/Reason/(DD/MM/YY) 2nd-

code/Reason/(DD/MM/YY

Ifthereisaswitchwithinthe3rdlineregimen,writeinthecodefortheswitchregimen,thereason code,andthedate,writte-nas(EC)Day/Month/Year(DD/MM/YY)

Ifthereisa3rdswitch,writethecodefortheswitchregimen,thereasoncode,andthedate,writtenas (EC) Day/ Month/ Year (DD/MM/YY) Reasons switch to 3rd lineregimen:

8=Clinical treatment failure, 9=Immunologic failure, 10=Virologic failure

The second page of the register is used to document ARV regimens or ART treatment interruptions after starting ART.

Under”Month o” ente rthe name of the month and they ear(EC) in which the patients in this cohort started ART. This applies for all the patients on this pag eof the register since they are all in the same cohort that started in this month. Under “Month 1” write the name of the next month and year (EC) and continue in this manner for all 36 columns. When your each the end of a calendar year, be sure to change the year.

For example, for the cohort of patients starting ART in Meskerem 2000:

Month o: Meskerem 2000

Month I:Tikmt Month 8:Ginbot

Month 2:Hidar Month 9:Sene

Month 3:Tahsas Month 10:Hamle

Month 4:Tir Month 11:Nehassie

Month 5:Yekatit Month I2: Meskerem2001

Month 6:Megabit Month I3:Tikmt

Month 7:Meazia Month I4: Hidaretc

N.B:When ever a patient is transferred from one ART register into another after completion of Current Register, it has to start at“Month 1”not “Month 0”.

At the end of each month, In the column for that month, enter the code of the regimen the individual collected in the month. If the individual did not collect drugs, write one of the following options to indicate the patients follow up status:

TO =Transferred Out. If TO transferred out to where

STOP=If the patient and the clinician discussed and decided to stop treatment for different reasons. LOST=If the patient has missed an appointment(not picked up drugs) for at least one month.

DEAD=Write date and status if the facility has been notified that the patient has died DROP=Lost to follow up for >3months

41-96

In the 6th,, 12th, 24th, and 36th months enter the regimen, functional status, weight/height, CD4 as described above.

For viral load at 6th, I2th, 24th, and 36th months, write the date VL sample collected as (EC) Day/ Month/Year (DD/MM/YY) on the upper row if viral load is performed at 6th,I2th,24th, and 36th months; on the lower row:write Viral Load Result: 1=Suppressed- if the viral load is< 50 copies per ml, 2= Low level viremia: if viral load is between 50 and 1000 copies per ml, 3=High Viral Load - if the viral load is >1000 copies per ml. For Follow up Cx Ca screening, Tx & refferal services every 24th months, write the codes foud as a foot note on the left side

Registration Status at start ART Cx Ca screening, Tx & refferal services TB / HIV Coinfection

Fluc

onaz

ole p

reve

ntive

ther

apy

(FPT

) (√)

Fill when applicable 1st Line Regimen 2nd Line Regimen 3rd Line Regimen

ART Start Date

(DD/MM/YY)

Unique ART Num-ber

MRN

Name

Age Sex (M/F)

Woreda

Func

tiona

l Sta

tus*

Weig

ht

Heig

ht / L

engt

h

MUAC

(cm

)

BMI /W

eight

for A

geNu

tritio

n Sc

reen

ing

Resu

lt wr

ite

code

WHO

Clin

ical s

tage

CD4 (

if ch

ild C

D4 %

)

Type

of c

ervic

alca s

cree

ning

(V

IA, H

PV)

Cx C

a Scr

eeni

ng r

esul

t (wr

ite

code

) Ma

nage

men

t of c

lient

s with

ce

rvica

l less

ions

(writ

e cod

e)

Refe

ral s

ervic

e fo

r wom

en

with

Cx l

esio

ns (

write

code

)Sc

reen

ed fo

r TB

(√) GeneXpert

(1)/Urine LF-LAM (2)

sent (√) TB Tr

eatm

ent

Star

t dat

e (D

D/MM

/YY)

6H/3HP/3HR prophy-laxis

(DD/MM/YY)

TPT com-pleted (Y, N)

Enrolled to DSD Model (DD/MM/YY)

CTX Start date DD/MM/

YY)

Usin

g an

y Mod

ern

Cont

ra-

cept

ive (w

rite c

ode)

Date

Ref

erre

d to

PMT

CT

(DD/

MM/Y

Y)

Orig

inal

Regi

men

Substitutions 1st code /

Reason / (DD/MM/YY)

Regi

men

Switch 1st code / Reason /

(DD/MM/YY)

Regi

men

Switch 1st code / Reason / (DD/MM/

YY)

Father, Grandfather Name

Kebele HNo.

Food Rx (√)

Scre

enin

g re

sult

(P/N

)

Result (P/N)

Com

plet

e da

te (D

D/MM

/YY

)

Type of DSD( Write code )

Stop date (DD/MM/

YY) Date

Re-

turn

ed

(DD/

MM/Y

Y)

2nd code / Reason / (DD/

MM/YY)

2nd code / Reason /

(DD/MM/YY)

2nd code / Reason / (DD/MM/

YY)

(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40)

Cohort MONTH:_____ Cohort YEAR 20 ____ ART Register

Functional Status * A= AmbulataryB= BedriddenW= Working

Nutritional Screening Result:(13)1= Normal2= Mild3= Moderate Malnutrition4=Sever Malnutrition5= Overwieght

Reasons for regimen change:-Substitutions 1=Toxicity/side effects 2=Pregnancy 3=Risk of pregnancy 4=Due to new TB 5=New drug available 6=Drug out of stock 7=Other reason (specify)

Resons for switch to 2nd/3rd-line Regimen:8=Clinical treatment failure9=Immunologic failure10=Virologic failure

Type of Cx Ca Screening result (0- 7):(17)0. Cx Ca screening not done1. HPV Negative2. HPV Positive3. VIA Negative4. VIA Positive: eligible for Cryo5. VIA Positive: Non-Eligible for Cryo6. Suspicious for Cx Ca7.Referal for screening

Management of clients with cervical lessions (0-5) :(18) 0. No treatment / further evaluation & managment 1. Cryotherapy2.Thermal ablation treatment3.LEEP srvice4. Further evaluation and managment service given to Suspicious for Cx Ca 5.Referred

Referal for Cx Ca screening & management (19) 0. Not refered 1. Refered for Cx Ca screening 2.Refered for Cryotherapy/Thermal ablation treatment3.Refered for LEEP srvice4. Further evaluation & managment suspicious cases of Cx Ca

FamilyPlanning Options (0-7):(33) 1=Condoms 2=Oralcontraceptive-pills 3=Injectable 4=Implant 5=Intrauterinedevice6=Vasectomy/ tuballegation 7=Absti-nence(nosex)

Follow-up Status at end of each month:On treatment (current regimen abbreviation)DEAD STOPPED ART (contiuned on other care)LOST (not seen X months) or DROP/Lost to follow-up RESTARTTransferred Out (TO). If TO trans-ferred out to where

Type of DSD (31) 1. 3MMD 2. ASM(6MMD)3. FTAR 4. CAG 5. PCAD. 6. DSD for Adolescent7. DSD for KP 8. DSD for MCH 9. DSD for AHD 10. Others

Reason For Change :1.Toxicity/ Sideeffects2.Due tonewTB3.Newdrugavailable4.Drug stockout5. Clinicalfailure6.Immunologicfailure7. Virologicfailure 8. Other

MOH V1 2013

Cohort MONTH:_____ Cohort YEAR 20 ____ ART Register

Reason For Change :1.Toxicity/ Sideeffects2.Due tonewTB3.Newdrugavailable4.Drug stockout5. Clinicalfailure6.Immunologicfailure7. Virologicfailure 8. Other

Months 0-6 Months 7-12 Months 13-24 Months 25-36

Month 0 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 26 27 28 29 30 31 32 33 34 35

36Re

gim

enFu

nctio

nal s

tatu

s Wt

CD4

Date VL sam-ple collected

Regi

men

Func

tiona

l sta

tus Wt

CD4

Date VL sam-ple collected

Regi

men

Func

tiona

l sta

tus Wt

CD4

Date VL sample collected Follow up Cx Ca screening, Tx & refferal services

Regi

men

Func

tiona

l sta

tus Wt

CD 4

Date VL sample collect-

ed

Ht VL Result( Write code ) Ht VL Result(

Write code ) Ht VL Result( Write code )

Type of Cx Ca Screening (write

code)

Management of clients with cer-vical lessions (write code)

Referal service for Cx Ca screen-

ing & manage-ment (write code)

Ht

VL Result( Write code )

(41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) 60 61 62 (63) (64) (65) (66) 67) (68) (69) (70) (71) (72) (73) (74) (75) (76) (77) 78 (79) (80) 81 (82) (83) (84) (85) (86) (87) (88) (89) (90) (91) (92) (93) (94) (95) (96)

Adult 1st Line Regimens:1d = AZT - 3TC - EFV 1e = TDF - 3TC - EFV 1g = ABC + 3TC + EFV 1j = TDF + 3TC + DTG1K = AZT + 3TC + DTG1i = Other specify

Adult 2nd Line Regimens:2e= AZT +3TC +LPV/r 2f =AZT+3TC +ATV/r2g=TDF + 3TC+-LPV/r2h= TDF + 3TC + ATV/r2i= ABC + 3TC+ LPV/r2j = TDF + 3TC + DTG2K = AZT + 3TC + DTG2L= Other specify

Adult 3rd Line Regimens:3a = DRV/r+DTG+AZT+3TC3b = DRV/r+DTG+TDF+3TC3c=DRV/r+ABC+3TC+DTG3e= DRV/r+TDF+3TC+EFV 3f= DRV/r+AZT+3TC +EFV3d = Other specify

Child 1st line Regimens4d = AZT+3TC+EFV4e = TDF+3TC+EFV4f = AZT +3TC + LPV/r4g = ABC + 3TC + LPV/r4i = TDF + 3TC + DTG4j = ABC + 3TC + DTG4K = AZT + 3TC + DTG4L = ABC + 3TC + EFV4h = Other specify

Child 2nd Line Regimens5e=ABC+3TC+LPV/r5f=AZT + 3TC + LPV/r5g=TDF + 3TC + EFV5h=ABC + 3TC + EFV5i= TDF + 3TC+LPV/r5m= ABC+3TC+DTG5n= AZT+3TC+DTG5o= TDF + 3TC + DTG5j= Other specify

Child 3rd Line Regimens6c= DRV/r + DTG + AZT +3TC6d = DRV/r + DTG +TDF+3TC6f = DRV/r+DTG+ABC+3TC6g= DRV/r +ABC+3TC+ EFV6h= DRV/r +AZT+3TC+EFV6e = Other specify

Other regimens for first line ,second line and third line : O 1st= Other first line regimen for Adult and Child patients O 2nd= Other second line regimen for Adult and Child patients O 3rd= Other third line regimen for Adult and Child patients

Viral Load Result :1=Suppressed- if the viral load is< 50 copies per ml 2= Low level viremia: if viral load is between 50 and 1000 copies per ml, 3=High Viral Load - if the viral load is >1000 copies per ml

Reason Left Treatment (put in month removed):TO = Transferred Out. If TO transferred out to whereSTOP = If the patient and the clinician discussed and decided to stop treatment for different reasons.LOST = If the patient has missed an appointment (not picked up drugs) for at least one month.DEAD = If the facility has been notified that the patient has died

Reason Left Treatment (put in month removed):TO = Transferred Out. If TO transferred out to whereSTOP = If the patient and the clinician discussed and decided to stop treatment for different reasons.LOST = If the patient has missed an appointment (not picked up drugs) for at least one month.DEAD = If the facility has been notified that the patient has died

MOH V1 2013


Health Centre /Clinic/Hospital Differentiated Service Delivery (DSD)

Register

SN Datum Comments

1. Serial Number Sequential serial number in registration book; to be entered on client’s registration card for later identification in register

2. Counseled and consented Write Y if the clinets is counseled to all DSD models if not write N in the upper space and Write Y if the clinets is consted to all DSD models if not write N in the lower space

3 Date of enrollment Write date of enrollment to DSD model, written as ( EC) DD/MM/YY

4 Type of model Write Type of Model 1. 3MMD 2.ASM (6MMD) 3. FTAR 4.CAD 5.PCAD 6. DSD for Adoles-ent 7. DSD for KP 8. DSD for MCH 9. DSD for AHD 10. Others

5 MRN Unique individual identifier used on medical information folder, for HC and hospital.6 UAN Write Patient’s unique ART number 7 Full Name Write the patient’s first name, father’s and grandfather’s name.

8 Age Enter the age of patient’s age in years – yr. For example, a 17-year-old child is entered as 17 yr

9 Sex M=Male; F=Female

10 Woreda/ Kebele Write the clients woreda and Kebele

11 Phone number Write the clients phone number

12 ART Start Date Enter date patient started ART, written as (EC) Day / Month / Year (DD/ MM/YY)

13 Months on ART Write months on ART in number

14 ART Regimen Write the code for the ART regimen that patient has been taking

15 Current Enrollemnt Model Write the patients current model as 1. 3MMD 2.ASM (6MMD) 3. FTAR 4.CAD 5.PCAD 6. DSD for Adolesent 7. DSD for KP 8. DSD for MCH 9. DSD for AHD 10. Others

16 If they are couples write UAN of the other partner If the client has couples write UAN of the other partner

17 New Model change and date changed If client model changed from one model to other write the newmodel and date the model changed

18 Reason for Model change and Date changed

Write the code for reasons change in client status on the upper space . 1. Died 2. Defaulted/ LTFU 3. Transferred out 4. Returned to conventional care 5. Moved to other DSD model 6. Unknown 7. Other and Write Date changed on the lower space

19 Follow Up Visit dates Write the next four follow up visit dates on the space provided

20 Remark Write any additional suggestions, comments…follow up appointment like visit dates

INSTRUCTIONS FOR DSD MODEL OF HIV CARE ENROLLMENT REGISTER

Region Write the region where the Health Facility is locatedZone Write the Zone where the Health Facility is locatedWoreda Write the woreda where the Health Facility is locatedName of Health Facility Write the name of the health facility where the Health Facility is located.Register begin date Enter the date of the first entry in the register, written as (EC) Day/Month /Year (DD/MM/YY)Register end date Enter the date of the last entry in the register, written as (EC) Day/Month /Year (DD/MM/YY)

Registration

ART Regimen

Current Enrolment

Model (write code)

If they are couples

write UAN of the other

partner

Follow Up

RemarkS. No

Counseled to all DSD

models (Y/N) Date of

enrolment

Type of model (write code)

MRN UAN Full Name Age Sex (M/F)

Woreda Phone

number

ART start date

Month on

ART

New Model change

(write code)

Reason for model change (write code)

Follow Up Visit dates

Date changed

Date changed

1st Visit date

2nd Visit date

3rd Visit date

4thVisit date

Consented (Y/N) Kebele

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Differentiated Service Delivery (DSD) Register

Type of Model : (Col. 4, 15, 17)1. 3MMD 2. ASM(6MMD) 3. FTAR 4. CAG 5. PCAD 6. DSD for Adolescent 7.DSD for KP 8.DSD for MCH 9.DSD for AHD 10.Others

Reason For Change :(18) 1. Died 2. Defaulted 3.Transfrred Out 7. Other 4. Returned to conventional care 5. Moved to other DSD model 6. Unknown


Health Centre /Clinic/Hospital HIV Care/ART Follow-Up Form

Facility Name ____________________________________________________ Name: _______________________________________________ Age __________years (Months for Children <5 years)

Sex M F Address: Region Woreda/Sub city Kebele___________ House No. ___________Telephone _____________ Patient Card No Unique ART No. __________________________ Date confirmed HIV+ (Retesting): / / (DD/MM/YY)

Type of HIV Test Rapid HIV tests DNA/PCR (for children) Client readiness: (date client is ready) / / (DD/MM/YY) Height (Adult) in cm: _______

HIV CARE/ART FOLLOW-UP FORM MINISTRY OF HEALTH

S/ US

Follow up date dd/mm/

yy

Mon

ths o

n ART

Weig

ht (K

g) E

dem

a+/-

BMI (

MUA

C fo

r pr

egna

nt w

oman

or b

edrid

den)

Preg-nancy

status /FPmeth-

od

Func-tional Status W,A,B

WHO

Sta

ge (1

-4 / T

1- T

4

TB S

cree

n - P

/N

Xpert-MTB/RIF(1)

TB

Trea

tmen

t / T

B Pr

ophy

laxis

Disp

ense

Dos

e (T

PT d

rugs

)

Adhe

renc

e fo

r TPT

(G,

F,P)

Side

effe

ct f

or T

PT d

rugs

(see

side

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Version: December_ 2021

HIV CARE/ART FOLLOW-UP FORM MINISTRY OF HEALTHClient readiness

Enter the date (dd/mm/yy) client is ready for ART initiation when client is coun-seled, adherence barriers addressed and client is willing to start ART Client Set HIV Prevention Plan D =Agreed to Disclose to partner/family/friend, PT= Agreed to bring partner for testingChT=agreed to bring children for testing,SSex=discussed &agreed to practice safer sex SubU=Decides to avoid or decrease Substance use ASS=Assessed for STISRX=client managed for STIFor children Fill in stage of HIV disclosure DS0 = No disclosure DS1=Satge1, about the illness, taking medicine, keeping healthy, DS2=Stage2, about germs, body soldiers, DS3=Stage3, use of terms like CD4, Viral Load, HIV

DISPENSE DOSE/ REGIMEN CODE

ADULT FIRST LINE CHILD FIRST LINE

1d = AZT - 3TC - EFV1e = TDF - 3TC - EFV1g = ABC + 3TC + EFV1j = TDF + 3TC + DTG1K = AZT + 3TC + DTG1i = Other specify

4d = AZT+3TC+EFV4e = TDF+3TC+EFV4f = AZT +3TC + LPV/r4g = ABC + 3TC + LPV/r4i = TDF + 3TC + DTG4j = ABC + 3TC + DTG4K = AZT + 3TC + DTG4L = ABC + 3TC + EFV4h = Other specify

ADULT SECOND LINE CHILD SECOND LINE

2e= AZT +3TC +LPV/r 2f =AZT+3TC +ATV/r2g=TDF + 3TC+-LPV/r2h= TDF + 3TC + ATV/r2i= ABC + 3TC+ LPV/r2j = TDF + 3TC + DTG2k = AZT + 3TC + DTG2l= Other specify

5e=ABC+3TC+LPV/r5f=AZT + 3TC + LPV/r5g=TDF + 3TC + EFV5h=ABC + 3TC + EFV5i= TDF + 3TC+LPV/r5m= ABC+3TC+DTG5n= AZT+3TC+DTG5o= TDF + 3TC + DTG5j= Other specify

ADULT THIRD LINE CHILD THIRD LINE

3a = DRV/r+DTG+AZT+3TC3b = DRV/r+DTG+TDF+3TC3c=DRV/r+ABC+3TC+DTG3e= DRV/r+TDF+3TC+EFV 3f= DRV/r+AZT+3TC +EFV3d = Other specify

6c= DRV/r + DTG + AZT +3TC6d = DRV/r + DTG +TDF+3TC6f = DRV/r+DTG+ABC+3TC6g= DRV/r +ABC+3TC+ EFV6h= DRV/r +AZT+3TC+EFV 6e = Other specify

DSD CODE

1. 3MMD 2. ASM(6MMD)3. FTAR 4. CAG 5. PCAD 6. DSD for Adolescent 7.DSD for KP8.DSD for MCH9.DSD for AHD10.Others

S/US Months on ART

S=Scheduled US=Unscheduled Duration in months since initiation of ART:0=ART Initiation date1week=1 week2weeks=2 weeks3weeks=3 weeks1= 1 month2=2 monthsIf not started on ART (Pre-ART) leave this column blank

TB SCREEN

SCREENFOR TB AT EVERYVISITAdult Adolescent1. Current Cough?2. Fever?3. Night sweats.4. Weight loss?P=(Positive screen)-Yes to any of the above---Evaluate for TB.N= (Negative screen)- No to all the questions above---assess for IPT eligibility

Children0-14years old1. Current Cough?2. Fever?3. Weight loss or poor weight gain?4. Contact history with TB patient?P=(Positive screen)-Yes to any one of the four---evaluate for TBN=(Negative screen)-No to all four---assess for eligibility to IPT Xpert MTB/ RIF (1)P= Positive N= Negative

LF_LAM (2)P= Positive N= Negative

Pain Assessment &Management

Assess for Pain &Manage asNP= No painS1= WHOStep1S2= WHOstep2S3= WHOstep3

Nutritional Status (adults )

BMI (wt/(ht2)) (for non-pregnant/non postpartum)

1= Normal(18.5-24.99kg/m2)2= Mild (17-18.49kg/m2)3=Moderate malnutrition

(16-16.99kg/m2)4=Severe malnutrition

(<16kg/m2) 5=Over weight (25-29.99 kg/m2)

NB: write the codes (1,2,3,4 or 5)

MUAC (for pregnant/postpartum /bedrid-den) 1= Normal (>23cm)2=Moderate malnutri-tion (19-23cm)3=-Severe malnutrition (<19cm for pregnant and postpartum /<18cm for bedridden)

TB PROPHYLAXIS TREATMENT ADHERENCE

6H1-6=Currently on INH prophylaxis (Number refers to months on 6H) 6H-C=Completed treatment6H- DC=discontinued for any reason3HP1-3=Currently on 3HP prophylaxis (Number refers to months on 3HP) 3HP-C=Completed treatment3HP- DC=discontinued for any reasonTB RX1-6=Currently on Anti-TB(num-bers refer to months on Rx)TB RXDC=discontinued TB Rx for any reasonTB Rx C=Completed anti TB Rx

Estimate adherence using the table below:Adherence % # Missed doses

G (Good) ≥95% (of 30 doses)<2 doses

of 60 doses)≤3 doses

F (Fair) 85-94% 2-4doses 4-9 doses

P (Poor) <85% ≥5 doses ≥10 doses

If Fair or Poor adherence, in why column note reason:1. Toxicity/ Side effects2. Share with others3. Forgot4. Felt better5. Too ill6. Stigma, discloser7. Drug stock out8. Lost/ ran out of pills9. Delivery/ travel problems10. In ability to pay11. Alcohol12. Depression13. Other

OI/ Opportunistic Cancers

NOI=No OI or Opportunistic cancerZ=Zoster BP=Bacterial PneumoniaPTB=Pulmonary TuberculosisEPTB=Extra pulmonary tuberculosisTO= Thrush oral EC=esophageal candidiasisUM=ulcers-mouthDC or DA=Diarrhea Chronic/AcutePCP=PneumocystispneumoniaCT=CNS ToxoplasmosisCM=Cryptococcal Meningitis NHL=Non Hodgkins Lymphoma KS=Kaposi’s Sarcoma CCa=Cervical cancerO=Other

Pregnancy Status/Family PlanningMethod Functional statusP=Pregnant(If pregnant, give estimated due date(EDD))PMTCT=Referred to PMTCT &indicate linkageWP=want to become pregnantNo FP=not pregnant& is not using any FP methodsFP=On Family Planning (enter code):1=Condoms2=Oral contraceptive pills3=Injectable4= Implant5=Intrauterine device6=Vasectomy/ tubal legation7=Abstinence(no sex)

Length / height/ HCMeasure length/height in cm for children younger than14 years at EVERY visit.Measure head circumference In cm for children youngerThan 3 years of age at EVERY visit

W=Working(able to perform usual work in or out of the house, harvest, go to school or, for children, normal activities or playing)A=Ambulatory (able to perform activities of dailyLiving)B=Bedridden (not able to perform activities of daily living)

DEVELOPMENTAL MILESTONES FOR CHILDA=Appropriate:Sitting without support …….3 to9months Standing with assistance……5to 11months Hands and knees crawling ….6 to1 3months Walking with assistance ……7 to14 months Standing alone…….8 to17 monthsWalking alone……. 9 to18 monthsDelay: Failure to attain milestones for ageRegression: Loss of what has been attained for age

Nutritional Status(Children) Nutritional Status(Older children &adolescents)W/H1=Normal/ Appropriate (> -1Z-score)2=Mild(<-1and> -2Z-score)3=MAM- Moderate Acute Malnutrition (<-2and>-3Z-score)

4=SAM-Severe Acute Malnutrition(<-3Z-score)

BMI for age(5-18yrs)1=Normal/appropriate (>-1Zscore)2=Mild(<-1and> -2Zscore)3=Moderate malnutrition(<-2and>-3Zscore)4=Severe malnutrition(<-3Zscore)*BMI forage for older children and adolescents.

SIDE EFFECTS REASONSFOR STOPPINGREGIMEN1. No side effects2. Nausea3. Diarrhea4. Fatigue5. Headache6. Numbness/tingling/pain7. Rash8. Anemia9. Abdominal pain10. Jaundice11. Fat changes12. Dizzy, anxiety, nightmare, depression13. Other

1. STOP=Stopped ART2. If STOP, In why column, note reason:3. Toxicity/side effects4. Treatment failure5. Poor adherence6. Illness, hospitalization7. Drugs out of stock8. Patient lack finances9. Other patient decision10. Other

REASONS FOR REGIMEN CHANGE VIRAL LOAD1. Toxicity/ Side effects2. Due to new TB3. New drug available4. Drug stock out5. Clinical failure6. Immunologic failure7. Virologic failure8. Other

Mark ‘*’ under VL column when requested/ speci-men collected, Write the amount and interpret as Suppressed- if the viral load is< 50 copies per ml, Low level vi-remia: if viral load is between 50 and 1000 cop-ies per ml and High Viral Load - if the viral load is >1000 copies per ml for clinical intervention

Cervical Cancer Screening& Treatment Type of Cx Ca Screening result (0- 6):0. Cx Ca screening not done1. HPV Negative2. HPV Positive3. VIA Negative4. VIA Positive: eligible for Cryo5. VIA Positive: Non-Eligible for Cryo6. Suspicious for Cervical Cancer 7.Referred for screening

Management of cervical lesions (0-4) 0. No treatment / further evaluation & manage-ment service given1. Cryotherapy2.Thermal ablation treatment3.LEEP service4. Further evaluation & management service given to Suspicious for Cervical Cancer5.Referred

In the follow-up date, in 2nd column if one of the options below applies, use raw next to the last visit to enter the appropriate information:TO=Transfer out LOST=not seen since ≥1 month,3 months DROP= lost to follow-up for >3 months STOP= When the clinician stop ART for different reason and patient is on follow up DEAD


Hospital/Clinic Hepatitis B Screening and Treatment

Register

RegistrationS.N Datum Comments

1 Patient’s name Write the full name of patient’s

2 Date enrolledWrite date patient enrolled into Hepatitis B treatment, written as (EC) Day/ Month/ Year (DD/ MM/YY)

3 Patient MRN Write unique individual identifier used on medical information folder.

4 Age Write age of the patients in years: Specify if not in years

5 Sex Write sex M= Male or F= Female

6 HBVL at Baseline Write patient’s Hepatitis Viral load count at baseline

7 HBVL at start of Rx Write patient’s Hepatitis Viral load count at the start of treatment

8 Status of HBeAg (+Ve/-Ve/ unknown)Write the status of Hepatitis-e antigen status either positive, negative or unknown

9 co-infection (code)Write the code for the co-infection found at the bottom of the Hepatitis B register

10 if HIV pos code of ART regimenWrite the code of ART regiment from patient chart if the patient is HIV Positive

11 clinical Status(Code)Write the code for the clinical status of the patient. This is found at the bottom of the HBV register.

12 eligible for treatment (Y/N) Write “Yes” if the patient is eligible for treatment or “NO” if not

13 indication for treatmentWrite the code for indication for treatment found at the bottom of the Hepatitis B register

14 Date treatment initiated (D/m/Y)Write the date patient started treatment as (EC) Day / Month /Year (DD/MM/YY)

15 code for treatment Write the code of the treatment at the bottom of the register

16 Follow up status (M0-m66)Write the code for the follow up status at bottom of the register from month 0 to Month 66 for column16-28

29 Reason for Discontinuation (Code) Write the code for Reason for discontinuation at the bottom of register

30 Remark Use this section for recording additional information

Instruction how to complete Hepatitis B Screening and Treatment Register

The register is kept in OPD and completed by Heath care providersInformation to be completed at front of the registerWrite cohort month and year (EC) at top of each page.

Region Write the region where the service is located

City/Town Write the town/city where the service is located

Health facilities Write the name of Health facilities

Hepatitis B Screening and Treatment Register Cohort month______________ Cohort year___________

Region:_____________________________________________

Name of Health facility : _________________________________ Health facility type _______________

S.No Patient’s name Date enrolled (DD/MM/YY) MRN Age Sex

(F/M)

HBVL at Baseline

(No)

HBVL at start of Rx

(No)

Status of HBeAg (+Ve/-Ve/ un-

known)

Co -infection (code)

if HIV pos code of ART

regimen

Clinical Sta-tus(Code)

Eligible for treatment

(Y/N)

Indication for treatment

(Code)

Date treat-ment initiated

(D/m/Y)

Code for treatment

Follow up status

Reason for Discon-tinuation (Code) Remark

m0

m3

m6

m12

m18

m24

m30

m36

m42

m48

m54

m60

m66

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 26 27 28 29 30

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Co-infection Code: (Col. 9)1.HIV2.HCV3.HIV & HCV4.Others

Phase of progression Code:1.Immune Tolerant2.Immune Clearance3.Inactive Carrier state4.Reactivation

Clinical Status Code: (Col. 11)1.No Cirrhosis2.Non-Dec Cirrhosis3.Dec Cirrhosis4.HCC with or without Cirrhosis

Indication for Treatment Code: (Col. 13)1 Clinical evidence of Cirrhosis 2 Detectable HBV DNA and Apri-score > 2 3 Adult >30yrs with persistent ALT above limit and HBV DNA >2000 Iu/ml regardless of HBeAg 4 HBeAg negative and HBeAb positive 5 Patients under immunosuppressive Therapy like Chemotherapy6 Co-infection with HIV

Treatment Code: (Col. 15)1.Tenofovir2.Entecavir3.Telbivudine4.Lamivudine5.Adefovir6.Peg-Interferon

Follow UP status Code: (Col. 16-28)1.Active (on Treatment)2.Dead3.LTFu4.Stopped Treatment5.Halted progression (specify)6.Progression not Halted (specify)7.Dropped

Reason for Rx discontinuation Code: (Col. 29)1. Side effect2. Drug to Drug interaction3. Out of Stock

LTFU: Lost follow up for the 1st, 2nd and 3rd visits

Dropped: patient lost follow up for more than three times

Health Center/Clinic / HospitalHCV Treatment Register


RegistrationS.N Datum Comments1. Patient’s name Write the full name of patient’s

2. Date enrolledWrite date patient enrolled into Hepatitis C care, written as (EC) Day/ Month/ Year (DD/ MM/YY)

3. Patient MRN Write unique individual identifier used on medical information folder.

4. Age Write age of the patients in years: Specify if not in years

5. Sex Write sex M= Male or F= Female

6. Vl quantitative (number) Write the patient’s Viral Load count at the start of the treatment

7. co-infection (code)Write the code for the co-infection found at the bottom of the Hepatitis C register

8. Initial ALT Write the initial Alanine Amino transaminase count

9. APRI Score

Write the APRI Score. (APRI Score refers to the ratio of Liver enzyme AST (Aspartate amino transaminase) to Platelet

A formula for calculating the APRI is given: APRI = (AST/ULN) x 100) / platelet count (109 /L).

10. initial liver Status (code) Write the code for “Initial liver status” at the bottom of the register

11. if HIV pos code of ART regimen Write the ART regimen code from the patient Chart if positive

12. History of prior treatment for HCV (Yes/No)

Write” Yes” if the patient had previous history of treatment for Hepatitis C or “NO” if no history of treatment

13. Genotype Write the Genotype of Hepatitis C

14. HCV treatment (code) Write the code of the treatment at the bottom of the register

15. Date treatment initiated (DD/ mm/YYYY)

Write the date patient started treatment for Hepatitis C as (EC) Day / Month /Year (DD/MM/YY)

16. Follow up status (Wk0-Wk 24)Write the code for the follow up status at bottom of the register from week 0 to Week 24 (for Column 16-20)

21. treatment completed (Y/n) Write “Yes” if treatment completed and “NO” if not

22. SVR 12 weeks Viral load (Vl No) Write the viral load count at 12 weeks of treatment

23. treatment Stopped (Y/n)Write “Yes” if the patient and clinician discussed and decided to stop the treatment

24. Dropped (Y/n) Write “Yes” if the patient is Lost to follow up more than 3 months

25. Died (Y/N) Write “Yes” if the patient died

26 Remark Use this section for recording additional information

Instruction how to complete Hepatitis C Register

The register is kept in OPD and completed by Heath care providersInformation to be completed at front of the register

Region Write the region where the service is located

City/Town Write the town/city where the service is located

Health facilities Write the name of Health facilities

Health Type Write the Type of Health facilities (Hospital/Health Center/Private/NGO

HCV Treatment Register

Definitions Treatment Outcome refers to status of patients after the supposed HCV treatment period (12, 24 or so weeks)Dropped: Refers to patients lost to follow up after the supposed HCV treatment period (12, 24 or so weeks as planned by the physician and patient)LTFU: Lost to follow up

Co-infection Code: (Col. 7)1.HIV2.HBV3.HIV & HBV4.others

Initial liver status Code: (Col. 10)1.No Cirrhosis2.Non Dec Cirrhosis3.Dec Cirrhosis4.HCC with Cirrhosis

Treatment Code: (Col. 14)1.SOf/DCV2.Sof/VEL3.Sof/LDV4.Sof/RBV5.Sof/VEL/Voxilaprevir6.Other

Follow up status Code: (Col. 16-20)1.Active on Treatment2.LTFU3.Stopped4.Died

Region:__________________________________________________________

Name of Health facility :____________________________________________Type of Health facility_____________________________________________

S.no Patient’s name

Date enrolled

(DD/MM/YY)

Pt MRN no.

AgeSex

(M/F)

VL quan-

titative (num-ber)

co-in-fection (code)

Initial ALT Apri ScoreInitial liv-er Status

(code)

If HIV pos code of art

regimen

History of prior treat-

ment for HCV (Yes/

No)

Geno-type

HCV treat-ment (code)

Date treatment initiated

(DD/ mm/YYYY)

Follow up statusTreatment outcome

Remark

Status

Wk0

Wk4

Wk8

Wk1

2

Wk2

4

Trea

tmen

t com

-pl

eted

(Y/n

)

SVR

12 w

eeks

Vi

ral l

oad

(VL

No)

Trea

tmen

t St

oppe

d (Y

/n)

Dro

pped

(Y/n

)

Die

d (Y

/N)

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 26

Health Center/Clinic / HospitalHIV Positive Clients’ Tracking

Register


S.No Datum Comments

1 S.No Write S.No on the column provided.

2 Client’s Name Write Client’s Name on the column provided

3 MRN Write Medical Record Number (MRN )on the column provided

4 Sex Write Sex on the column provided

5 Age Write age on the column provided

6 Address (Woreda/Town) Write Address (Woreda/Town) on the column provided

7 Phone Number Write client’s Phone Number on the column provided

8 Date HIV tested Positive Enter the date of HIV tested positive.

9 Entry points Write code number (1-30) of the entry points listed on the footer of the register. Eg 1=TB Clinic

10Date Linked to care& treatment

Enter date linked to care and treatment.

11 Date started on ART Enter date on which ART started.

12 UANWrite Unique ART Number(UAN) if ART is started with in or outside the health facility

13If Not Initiated ART same day , reasons

If ART is not initiated on the same day of testing, write code number of the reasons listed on footer of the register.

14 Name of refrred HFFor cases referred to other HF, specify the name of the facility and Health Facility telephone contact.(Document the Phone number of the health facility on the Remark Columen)

15 Plan for Next Steps

If patient is not initiated ART, write down your next plan or intervention (Write Code Number) and ensure that the information is documented on the local language version of “Treatment Not Initiated Follow up Form” for tracking, counselling and linking to care and treatment.

16Final outcome After the intervention

The outcome after interventions should be documented and reported (enter code number of the outcome on the footer of the register).

17 Remark Any comment, suggestion etc, that the provider would like to document

Instruction for Completing HIV Positive Clients’ Tracking Register

Region: ________________________________________________________ Zone/Town__________________ Woreda__________________

Name of the Health Facility ________________________________ Month: ___________________

S.NO Client’s Name MRN Sex(M/F) Age

Address (Woreda/

Town)

Phone Number

Date HIV tested

Positive

Entry points (write code)

Date Linked to care & treatment

Date started on ART

UAN (if ART is initiated)

If not initiated ART same day, reasons ( Write

Code )

Name and phone no of refrred HF

Plan for Next Steps

(Write code )

Final outcome After the

intervention (Write code )

Remark

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

HIV Positive Clients’ Tracking Register

1.TB clinic 2.OPD1 3. OPD2 4. OPD3 5. OPD4 6. STI 7.Dermatology 8. Pedi OPD1 9. Pedi OPD2 10. Malnutrition 11. Other OPD 12. VCT 13 ANC Client 14. ANC Partners 15. L&D Clients 16. L&D Partners 17. PNC Clients 18. PNC Partners 19. HEI 20. Medical ward 21. Pedi Ward 22. Gyn Ward 24.Index case testing children 25. Index case testing: partners

26. HF Outreach testing 27. Referred from community testing outlets. 28. Public HF 29. Private HF 30. NGO HF

Reason for Not Initiated: (Col.13)1. Referred TX Not Initiated 2. Declined 3. Died 4. Known+ on ART5. On adherence preparation6. On OI management 7. Other Specify

Plan for next step: (Col.15) 1. Linked to case managers for further counselling and tracking 2. Address adherence barrierrs 3. Initiate ART when the patient is ready after OI management

Final Out come: (Col.16) 1. Started ART (Date of ART initiation ) 2. Declined 3. Died 4. Confirmed referral & started ART in other facility (Specify UAN)5. Lost to Follow up 6.other

Entry points: (Col. 9)

Same HF:Other sites/HF


Health Centre /Clinic/Hospital HIV Self Testing Register

S.No Data Elements Instruction

1 S.No Put consecutive serial numbers, that help in auditing if the number of sheets in the register is intact or not.

2Client Name /UIN/ , UIN, Phone No. & Physical address

Write full name (Frist Name/Father Nam/Grandfather Name) of person who collected the HIV self-test kit for their contacts,UIN for unique identifier, Phone number of contact person on each box provided and write woreda/town, Kebele, House number/Establishment (Hotel, cafeteria, Bar,,,)for each address

3 Age and Sex (M/F) Write the age and Sex of client who collected HIVST Kit

4 Marital Status Write marital status with (code 1-4) 1.Never Married 2.Married 3.Separated/Divorced 4.Widowed

5Target Population and Date DD/MM/YY/

Write Target population group with (code 1-9) 1. FSW 2. Partner of FSW 3. Partner of HIV positive index 4. Partner of PMTCT clients 5. Long distance truck drivers (LDTD) and their assistant 6. Daily Laborer/mobile workers 7. Widowed/ divorced/ remarried 8. Vulnerable adolescents and youth clients (18- 24) years old) 9. Others, Write date client took HIVST kit Write specific date HIV self-test kit distributed either through secondary distribution or direct distribution for beneficiaries.

6 Pre-test information

Pretest Information & test procedure information on HIVST provided (Y,N): Write (Yes) if pretest information was provided with HIV self – test procedure detail information; write (No) if pretest information and test procedure not provided. HIVST kit provided with leaflet, information card and HIVST video (Y/N): Write (Yes) if HIV self-test kit provided with leaflet, information card and video and (No) of even 1 item not provided as they all are equally important.

7 HIVST kit distributed by (Write Code)Write specific contact person through which HIV self-test kit distributed by code number 1-6 on the column. (Code: 1. Nurse counsellor 2. ART provider 3. AS/CMs 4. PNs/Pes 5. MSGs 6. Health extension work-ers(HEWs) 7. Other (specify)

8Place of Kit Distribution

Write place of Kit distribution with the (code 1-3) based on site of distribution 1. Health Facility 2. Commu-nity 3. Othes

Kit Information

9 Kit Name Write Kit Name

10 Kit Batch No Write Kit Batch No

11 Kit Expire Date Write Kit Exp. Date

12 Tested Before (Y,N) Write Y if the client was tested before and N if not tested

13 Prior HIV test result (P/N/I) Write Previous HIV test result as P= for Positive, N= for Negative, I= for Inconclusive

14 Duration since last test ( in mths) Write how long it has been since the client was last tested in months

15 HIVST Implementation Modalities Write the HIVST Implementation Modalities as 1. Assisted 2. Un assisted

HIVST Testing Status

16 Provided with HIVST(Y/N) Write Y if Provided with HIVST and N) if not,

17 Tested with HIVST (Y/N) Write Y if Tested with HIVST and N if not,

18 HIVST Tested Reactive (Y/N) Write Y if HIVST Tested Reactive and N if not,

19 HIVST Confirmed positive (Y/N) Write Y if HIVST Confirmed positive and N if not.

20 Post-Test Counseling Status (Y/N) Write Y if the client has received post-test counseling and N if not.

21Proactive follow up conducted through:

Write codes through which proactive follow up was provided: 1.Self reported 2. Provider 3. Adherence Supporters/Case Mmanagers 4.Peer Navigators/peer educators 5.Mothers Support Group. 6. Health extension workers 7. Others

22 Date Linked to ART Write the date client is linked to ART on the space provided

23 Date ART started Write the date client started ART on the space provided

24 UAN of newly identified HIV positive Write the UAN if client started ART on the space provided

25Date new HIV Positive contact linked to Partner &Family Based ICT service

Write the date new HIV Positive contact linked to P&FB ICT service

26 If not linked to P&FB ICT (Code 1-3)Write (Code 1-3) if not linked to P&FB ICT service: 1.Referred 2. Declined 3.Other

27 Disclosure Staus Write Y if the client disclosed his/ her HIV status after enrollment to ICT services and N if not disclosed

PrEP services cascade for HIV Negative Sero Discordant Couples

28 Assessed for PrEP (Y, N) Write Y if the client assessed for PrEP services and N if not

29 PrEP eligibility (E, NE) Write E if the client is eligible for PrEP services and N if not

30 Started Oral PrEP (Y,N) Write Y if the client started oral PrEP and N if not

31 Date Started PrEP Write the date client started PrEP on the space provided

32 RemarkDocument all valuable information you think and not captured in the register or any additional information of the client

Instruction for Completing HIV Self testing Register

Client Information HIVST kit distribution Status Previous HIV Test Status HIVST Testing Status Linkage to care & treatment Disclosure Staus HIV Prevention Services

RemarkS.N

Client Name Age

Marital Status

Target Population

( 1 - 9 )

Pre-test information

Kit distributed by: (Write

Code)

Place of Kit

Distribution (1. Health

Facility 2.

Community 3. Othes)

Kit Information

Tested Before (Y,N)

Prior HIV test

result (P/N/I)

Duration since last test ( in mths)

HIVST Implementation

Modalities

Prov

ided

with

HIV

ST (Y

/N)

Test

ed w

ith H

IVST

(Y/N

)

HIVS

T Te

sted

Rea

ctive

(Y/N

)

HIVS

T Co

nfirm

ed p

ositi

ve (Y

/N)

Post-Test Counseling

Status Proactive FU conducted for

linkage through: ____

(write code)

Date Linked to ART

Date ART

started

UAN of newly

identified HIV positive

Date

new

HIV

Pos

itive

Con

tact

link

ed to

P&

FB IC

T se

rvic

e

If no

t lin

ked

to P

&FB

ICT

(Cod

e 1-

3)

Has the client

disclosed his/ her

HIV status after

enrollment to ICT

services? ( Y, N,)

PrEP services cascade for HIV Negative Sero Discordant Couples

Pretest Information & test procedure information on HIVST provided

(Y,N)

UINSex

(M/F)Date DD/MM/YY/

HIVST kit provided with leaflet,

information card and HIVST video

(Y/N)

Kit Name

Batch No Ex

p.

Date

1. A

ssis

ted

2. U

n as

sist

ed Has the client received post-test

counseling? (Y, N,)

Phone No. & Physical address Assessed for PrEP (Y, N)

PrEP eligibility

(E, NE)

Started Oral PrEP

(Y,N)

Date Started

PrEP (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) (26) (27) (28) (29) (30) (31) (32)

Partners’s Name:

Partners’s Name:

Partners’s Name:

Partners’s Name:

Partners’s Name:

HIV SELF TESTING REGISTER

Target population group (5)1. FSW 2. Partner of FSW 3. Partner of HIV positive index 4. Partner of PMTCT clients 5. Long distance truck drivers (LDTD) and their assistant 6. Daily Laborer/mobile workers 7. Widowed/ divorced/ remarried 8. Vulnerable adolescents and youth clients (18- 24) years old) 9. Others

AF: If not linked to P&FB ICT (column 26)1.Referred2. Declined3.Other

Month______________Year______________

Marital Status (Column 4) 1.Never Married 2.Married3.Separated/Divorced4.Widowed

Kit distributed by (Column 7):1. Nurse counsellor 2. ART provider3. AS/CMs 4. PNs/PEs 5. MSGs 6. HEWs 7. Other (specify)

Proactive FU linkage (Column 21) :1.Self reported 2. Provider3. AS/CMs 4.PNs/PEs5.MSG. 6. HEWs 7. Others)

HIV Rapid Testing Logbook


Region:________ Zone/Sub City:________ Woreda:________ Start Date : ____/___/___ End Date : ____/___/___ Health Facility Name: ______________ Testing Point Name: ______________ Logbook Number:____________

Instructions for HIV Rapid Testing Logbook

Location information to be completed at front page of the Logbook Region: Write the region where the HTS log book is

located Zone/Sub City Write the Zone /Sub city where the HF is located Woreda: Write the Woreda where the HF is located Start Date Enter the date of the first entry in the logbook,

written as (EC) Day /Month/Year(DD/MM/YY) End Date Enter the date of the last entry in the logbook,

written as (EC) Day /Month/Year(DD/MM/YY) Health Facility Name Write the name of the HF Testing Point Name: Write the Service Delivery Point (SDP) where the

testing is performed ( E.g.: VCT, OPD, IPD, Emergency, ART,ANC,L&D….etc.)

Logbook Number Write the Logbook Number as 1,2,3…. Introduction and Background This logbook is being tested as a tool to streamline the work process. Appropriate and consistent use of this logbook make testers’ workload lighter and more efficient. Additionally, this log book is critical to improve the quality of data recorded during HIV testing. For example, never use “white-out” if a mistake is made. Instead, put a single line through the mistake and initialize and date for Quality Assurance purposes. For example, this is a mistake and should be crossed out. Everyone makes mistakes. Knowing where mistakes occur most often will help improve systems. PAGE TOTALS at the bottom of each page will be used to evaluate the performance of individual kits. Please try to be consistent and use the same test kit repeatedly for Test-1, Test-2, and Test-3. When the same kit cannot be used, please START A NEW PAGE so that PAGE TOTALS are restricted to one test kit. Please use black or blue ink. Please do not record data with a pencil. Guidelines are provided below for each of the data fields (columns) in the logbook. The guidelines for interpretation of results are representative of most kits, but please be aware of differences in kits and follow manufacturer guidelines completely. Start a new page at the beginning of each month. Columns in the Logbook

Column No.

Data Element Description

1 Serial Number Write consecutive numbers in each row. Each row is associated with one patient/client. Some patients/clients might have data recorded in more than one row. For example, if one of the tests is invalid (INV) and repeat testing needs to be performed. In this case, a note is made in the Remark column and results of the repeat test are recorded on a subsequent row – ideally the very next row Sequential.

2 Medical Record Number (MRN)/Client Code.

Write Unique individual identifier / Medical Record Number used on medical information folder, for HC and Hospital . Write client code in case of VCT. Most sites have intake registration forms with specific medical record number that contain patient information. If possible, please avoid writing patient names on this Rapid Test logbook for confidentiality reasons.

3 Couple code Write unique couple code for those clients who came as a couple

4 Counselor Code Write unique code for counselor

5 Age Write age of the client /patient in years; Specify if not in Years.

6 Sex Circle ‘M’ for Male and ‘F’ for Female.

7 Requesting Unit

Write code of the Unit where the test is conducted as

A. VCT B. TB C. STI D. OPD E. IPD F. PMTCT G. Emergency

H. Other Specify

8 Reason for Testing

Write code for the reason of HIV testing as I=Initial , R= Retest for ongoing risk , V=Validation when discordant happen A= retest for confirmation before ART initiation , S= Confirmation for reactive HIV Self Test result

9 Date Tested (DD/MM/YY)

Write the date (day/month/year) when test was performed as : DD/MM/YY

10 HIVTest-1*

Write the kit name, lot number, and expiration date in the space provided at top of column. When the same kit cannot be used, please start a new page so that PAGE TOTALS are restricted to one test kit. Keeping track of this information is critical for Quality Assurance. Test-1 Results Record results of the FIRST test performed in this section – according to individual kit instructions. • For NON-REACTIVE result, circle NR. No SECOND test is needed. Proceed to

section on Final Results and circle NEG. • For REACTIVE result, circle R. For all reactive FIRST tests, a different SECOND

test must be done immediately (those results are recorded in the Test-2 section). • For INVALID result, circle INV. The test is invalid if there is no line in the control

window – even if there is a line in the patient/test window. If this happens, record this result (circle INV) and repeat using the same test.

11 HIVTest-2*

Write the kit name, lot number, and Expiry date in the space provided at top of the column. When the same kit cannot be used, please start a new page so that PAGE TOTALS are restricted to one test kit. Keeping track of this information is critical for Quality Assurance. Test-2 Results Record results of the SECOND test performed according to the test-2 kit instructions.

• For NON-REACTIVE result, circle NR. • For REACTIVE result, circle R.

For INVALID result , circle INV.

12 Parallel Repeat Test results

**Is a Repeat test needed? If results of the FIRST and SECOND test different (i.e., the FIRST is REACTIVE and the SECOND is NON-REACTIVE), both tests (FIRST and SECOND) must be parallely repeated. Parallel Test-1 Result

• For NON-REACTIVE result, Circle NR. • For REACTIVE result, Circle R. • For INVALID result Circle INV

Parallel Test-2 Result • For NON-REACTIVE result, Circle NR. • For REACTIVE result, Circle R.

For INVALID result, Circle INV

13 HIV Test-3* Write the kit name, lot number, and Expiry date in the space provided at top of the column . When the same kit cannot be used, please start a new page so that PAGE TOTALS are restricted to one test kit. Keeping track of this information is critical for Quality Assurance. Test-2 Results Record results of the SECOND test performed according to the test-2 kit instructions.

• For NON-REACTIVE result, circle NR. • For REACTIVE result, circle R.

For INVALID result, circle INV.

14 Final Result* Interpret and Circle NEG/POS/IND in the Final Results column as per the New –HIV Testing Algorithm. Refer the following table for interpreting Final Results:

SERIAL Scenario

Test-1 Test-2 Repeat Parallelly Test-3 Final Results Test-1 Test-2

1 NR Not Needed Not Needed Not Needed Not Needed NEG 2 R NR R NR Not Needed NEG 3 R NR NR NR Not Needed NEG 4 R R Not Needed Not Needed R POS 5 R R Not Needed Not Needed NR IND

Note: Always follow the national HIV rapid testing algorithm. *In parallel testing ,even though it is rare, If you get Test 1 - NR; Test 2 - R after repeated Test 1 and Test 2; Repeat Test 1 and report the final result if negative, if positive on Test 1 follow the algorithm again.

15 Referred to* Write the code where the client is referred to from the list at the bottom of the page e.g. if the client/patient is referred to ART unit, write “A” in the column , write “B” if referred to laboratory if initial and

retest is discordant. Referred to: A – ART C - Nearby facility/lab B – Laboratory (initial and retest is discordant) D - Others (Specify)

16 Target Population Group* A- FSW C-Prisoners E- OVC G - Children of PLHIV I- General population B-Long distance truck drivers D-Mobile Worker/Daily laborer F- Partner of PLHIV H - Other MARPS (Widowed ,Divorced ,Separated ,Re-Married)

17 Tester Initials

Write Tester Initial name performing this test. ( Eg : Abebe Kebede as AK )

18 Remark Use this section for recording additional information. Write a code as described at the bottom of the table. A - For kit expired and opened new kit B - IND specimen sent to reference lab C - Asked patient to return in 14 days

MONTHLY SUMMARIES Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ Specify Month and Year __________________________________ Specify Month and Year __________________________________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL POSITIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________ TOTAL NEGATIVE __________ MALE __________ FEMALE __________

TOTAL INDETERMINATE __________ MALE __________ FEMALE __________ TOTAL INDETERMINATE __________ MALE __________ FEMALE __________


PAGE Totals

Note: The term Inconclusive(INC) and Indeterminate (IND) can be used interchangeably. * Test is considered invalid (INV) if control line does not develop, irrespective of presence or absence of client line. If invalid, please record and repeat using the same test on a new row. ** Final interpretation is considered indeterminate (IND) or inconclusive (INC) if Test-1 and Test-2 results are the same i.e. both are Reactive and a 3rd Test result is non-reactive Supervisor Signature and Date

Serial No.

MR

N/C

lient

Cod

e

Cou

ple

Cod

e

Cou

nsel

or C

ode

Age

(Sp

ecify

if n

ot in

ye

ars)

S

ex

Req

uest

ing

Uni

t

(wri

te c

ode)

Rea

son

for

Tes

ting

(w

rite

cod

e)

Dat

e T

este

d

(dd/

mm

/yy)

HIV Test-1*

Kit Name ______________ Lot No. ______________ Expiration Date _____/_____/___

HIV Test-2*

Kit Name _______________ Lot No. _______________ Expiration Date _____/_____/____

Parallel Repeat Test Results HIV Test-3*

Kit Name _________________ Lot No. _________________ Expiration Date _____/_____/_____

Final Result**

Ref

erre

d to

(wri

te c

ode)

Tar

get p

opul

atio

n C

ateg

ory*

(w

rite

cod

e)

Tes

ter

Initi

als

Remark

Test-1

Test-2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

M F / / NR R INV NR R INV NR R INV NR R INV NR R INV NEG POS IND



















Total non-reactive/negative

Total Reactive/positive

Total Invalid* Total Indeterminate**

Total Tests

REFERD TO

A - ART B -Laboratory C-Nearby Facility/lab

REQUESTING UNIT

A – VCT B – TB C – STI D – OPD E – IPD F – PMTCT G – Emergency H- Other -Specify

TARGET POPULATN GROUP* A-FSW B-Long distance truck drivers C-Prisoners D-Mobile Worker/Daily laborer E- OVC F-Partner of PLHIV G-Children of PLHIV H -Other MARPS (Widowed, Divorced, Separated , Re-Married) I.- General Population

REMARK

A – Kit expired and opened new kit B – IND specimen sent to reference lab C – Asked patient to return in 14 days

REASONS FOR TSTING

I - Initial Testing R - Retesting for ongoing risk A - confirmation before ART initiation V - Verification when discordant happen S-confirmation for reactive HIV Self-Test result


Health Centre /Clinic/Hospital Index Case Testing Register

SN Data Elements Description

1 S.NoPut consecutive serial numbers, that help in auditing if the number of sheets in the register is intact or not. Also match this S.N with ICT follow up tool Serial Number

2

Name of the index case Write the full name of index case in the upper row

Index MRN/UAN Write the Medical Record Number and Unique ART number of index case in the second row

Phone No. & Physical address of index

Write the index’s case Physical address & telephone numbers in the third to sixth rows

3Age Write the age of index case at the time of registration

Sex (M/F) Write the sex of index contacts M for male and F for Female

4 Target population group ( 1-7) and Prioritizing Criteria ( 1 - 7 )

Write the Target population group the client belongs to (write code) 1. FSW 2.Long distance truck driver 3. Mobile workers/Daily laborers 4. OVC 5. Prisoners 6. Other MARPs 7. General Population Write Prioritizing Criteria the client belongs to (write code ( 1 - 7 )) 1. Newly Diagnosed 2. PLHIV with HVL & Adult 3. PLHIV restart ART & Adult 4. PLHIV in Care with STI 5. Enrolled @ PMTCT 6.Key population (Female sex workers) 7. Other (Specify)

5

Date Tested HIV+ Write the date index patients tested HIV positive on frist row.

Linked to care( Y/N) Write the linkage status if linked Yes and N if not linked to care on second row.

ART started (Y/N) Write the ART initiation status if started Yes and N if not started ART on 3rd row.

Date ART Started Write the date index patients started ART on 4th row.

Linked to CBS (Y/N) Write the linkage status if linked Yes and N if not linked to CBS services No.

6

If newly diagnosed (1), Is Case Report Form (CRF) completed ? (Y,N)

For newly diagnosed clients Check either CRF is completed or not.write Y is it is yes or write N if Not performed NB: Pass this column for all clients who are not newly diagnosed and at sites where CASE BASED Surveillance ( Recency testing ) is not performed.

Date Write the date CRF Completed as (DD/MM/YYYY)

CBS ID Write serial number of case report form /CRF/ for CBS ID

Initial CBS ID /ICBS ID/:Write down Initial CBS (ICBS) ID in case when contacts become an index case, i.e subsequent seeds indexes Id will be entered so that social networking is optimized.

Is s/he Eligible for recency testing ? Is s/he Eligible for recency testing ? Write E if s/he is eligible or Write NE if s/he is not eligible

7

If newly diagnosed (1), Is s/he Tested for Recency testing ? (Y,N)

For newly diagnosed clients write either recency testing was performed or not; Write Y if yes or Write N if Not performed NB: Pass this column for all clients who are not newly diagnosed and at sites where CASE BASED Surveillance (Recency testing) is not performed.

Date Write the date the Recency testing was performed

Recencty test result: Probable Recent (R), Long-term (LT) Inconclusive (IR)

Write the result of the Recency testing as: R for probable Recent infection; LT for Long-term (LT) and wrtite Inconclusive (IR) if the testing result is inconclusive/invalid.

8 Case Classifications

Check either case 1 or case 2 or case 3 based on classification using CRF section F and section I. Case 1 (C1): Newly diagnosed individuals age>=15 years with probable recent infection Case 2 (C2): Newly diagnosed individuals age>=13 years with current risk factors and identification with a KP group Case 3 (C3): All other newly diagnosed children, adolescents, or adults not classified by C1 and C2

9

ICT Service offered If index case testing service Offered for eligible Index Cases Write Y if not offered write N.

Date Offered Write the date the service is offered as (DD/MM/YYYY)

Client Accepted If the index client accepted and interviewed for index case testing, writeY if service not accepted write N.

Accepted Date Write the date the result is accepted as (DD/MM/YYYY)

If No, Indicate Why? (1-6) G: If the client don’t accept ICT services, write the reason with the following codes : 1. No reason 2. No time for elicitation interview 3. Do not believe services are confidential ( Fear of disclosure ) 4.Afraid of intimate partner violence 5. Prefer to go to Other HF for this service 6. Other (Specify)

10 Name of Contacts Elicited Write full name of elicited contacts (if blank, contact not elicited).

11 Age Write the age of index contacts at the time of registration

12 Sex (M/F) Write the sex of index clients M for male and F for Female

13 Contact category Write the Contact category 1.Sexual Partner 2. Child, < 15 years 3.Parent of an index child 4. Siblings ( If Index is a child )

14 IPV Risk Assessment Conducted (Y, N)

If IPV risk assessement conduct, choose Y , if not choose N.

15 IPV risk assessment outcome write the Intimate Partner Violence (IPV) risk assessment Outcome after asking the client: (write codes 1 to 5) 1. Physical 2. Emotional 3. Sexual 4. No IPV 5. NA _ Child (for child contacts)

16 If there is high risk of IPV, is s/he linked to PGBV care?

If the client has any form of of Intimate patner violence history; is he/ she linked to post Gender based violence care Mark(√) Y if linked or N if not linked

17 Has the index client already Disclosed his/ her HIV status?

After assessing the index client’s HIV status disclosure status to each partner; Write Y if disclosed and Write N if client has not disclosed HIV status to partner yet . This can be left blank for child contacts

18 Notification plan/Method write the code 1 to 5 as per the agreed notification plan; 1. Client 2. Contractual 3. Dual 4. Provider

19 Phone no. & Physical address Write the contact’s Physical address & telephone numbers

20, 22, 24 Contact trial date : 1st , 2nd, & 3rd Write the date of the 1st, 2nd, & 3rd contact trial date as (DD/MM/YYYY)

21, 23, 25 Outcome of Contact Trial 1st, 2nd, 3rd trial

write the out come of the 1st,2nd & 3rd contact trial with code; (1 to 6) 1. Partner contacted & gave appointment date to come to the facility. 2. Partner contacted but decline to come 3. Partner contacted but contact prefer to go to other HF for HIV testing 4. Partner Requested to be contacted again 5. Unable to Contact ( number not reachable, contact not found, wrong phone number ,...)

26 Notified face to face (Y,N) If the contact was notified face to face , Write Y . If not notified, Write N.

ICT Registration Book Instructions

27 Previous HIV test Status : Tested Before

If contact is tested before write Y, if contact has no know previous HIV test result write N. Leaving these columns (27, 28 and 29) blank indicate no previous test result or not done

28 Prior HIV test result If previous HIV Test Result reported by contact write N for negative and P for positive.

29 Duration since last test write the time passed since last tested for HIV in months

30 HIV Self-Test: Date HIV self-test kit distributed to the client

HIV Self-test : Write the date HIV Self-test distributed to the client ( DD/MM/YYYY)

31 HIV Self-Test: Date contact reported Self-test result

HIV Self-test : Write the date the contact reported the HIV Self-testing result ( DD/MM/YYYY)

32 HIV Self-Test: Contact HIV self-testing result ( R, NR)

HIV Self-test_ Write the HIV self-testing result reported : R_ Reactive, NR_Non reative

33 Date contact tested for HIV If contact is provided HIV testing Service write the date of test (DD/MM/YYYY)

34 Contact HIV test result (P/N/I) Write the result of HTS as : P for positive. N for negative and I for inditermined

35-37

Is s/he Eligible for recency testing ? Is s/he Eligible for recency testing ? : Write E if eligible or write NE if not eligible

If newly diagnosed (1), Is s/he Tested for Recency testing ? (Y,N)

For newly diagnosed clients write either recency testing was performed or not; write Y if yes or write N if Not performed NB: Pass this column for all clients who are not newly diagnosed and at sites where case based Surveillance (Recency testing) is not performed.

Recencty test result: Probable Recent (R), Long-term (LT) Inconclusive (IR)

Write the result of Recency testing; on R for probable Recent infection and on LT for Long-term (LT) and wrtite Inconclusive (IR) if the testing result is invalid.

38 Date Linked to ART Write the date HIV positive contact linked to ART (DD/MM/YYYY)

39 Date started ART Write the date HIV positive contact started ART (DD/MM/YYYY)

40 UAN of newly identified HIV positive Document the UAN of the Positive contact Identified

41 Date new HIV Positive Contact (>15 yrs.) linked to ICT service

Write the date HIV Positive contact(> 15 years) linked to index case testing(DD/MM/YYYY)

42 If newly diagnosed HIV positive Is not linked to ICT

Write why the newly diagnosed contact is not linked to ICT service: Write code: 1.Referred 2. Declined 3.Other

43-46

PrEP services cascade for HIV Negative Sero Discordant Couples : Assessed for PrEP

This column is filled for the regular current partner (if there are more than one HIV negative discordant sexual partners) write Y , if the HIV Negative Sero Discordant regular partner is Assessed for PrEP and write N if not assessed

PrEP eligibility Write E if elegible; Write NE if not eligible after assessing the serodiscordant negative partner of the couple

Started Oral PrEP Write Y if contact started of PrEP or Write N if client is eligible but not started . Pass the column if contact is not eligible

Date Started PrEP write the date the eligible contact started PrEP (DD/MM/YYYY)

47-49

Adverse Events for IPV If there is any incidence of any kind of intimate partner violence write Y, ; if not write N.

If Yes to Adverse Events noted, Write the adverse event type

If there is any Adverse events of any kind occurred indicate AE type with code 1. Divorce 2. Loss of relationship 3. Loss of support 4. Stigma 5. Job loss 6. Social exclusion 7. Verbal abuse 8. Physical abuse 9. Loneliness 10. Cessation of sexual intercourse 11. Marital discord 12. Taking away access to your children 13. Other (specify)

Linked to PGBV care (Y,N) if the client is linked to appripriate service for ocuurred adverse events write Y, if not linked write N.

50 Case Closure Status

Write code 1 to 4 ) according to each elicited contact outcome: 1. Successful Intervention: Contact notified, HIV status known and linked for appropriate services. 2. Intervention complete: Contact notified HIV status known but not linked to appropriate services 3. Intervention partially completed: Contact notified, but HIV status unknown (e.g. Declined ICT services) 4. Intervention incomplete: Contact was not notified (e.g. Out of jurisdiction, unable to locate)

51 Remark Put any relevant information which is not captured in the previous columns.

Index Case Information & Service Provided Elicited Contacts Information & Services Provided

RemarkS.N

Name of the index case

Age

Prio

ritizi

ng C

riter

ia (

1 - 7

)

Date Tested HIV+ If newly diagnosed (1): ICT service

Offered (Y, N)

Name of Index Contacts Elicited Age Sex (M/F)

Con

tact

cat

egor

y (c

ode

1-4)

IPV

Risk

Ass

essm

ent C

ondu

cted

( Y

, N)

IPV

Risk

Ass

essm

ent O

utco

me

(1-5

)

If there is high risk of IPV, is s/he

linked to PGBV care?

(Y,N)

Has the index client

already Disclosed

his/ her HIV status? ( Y,

N,)

N

otific

ation

Pla

n/M

etho

d (C

ode

1 - 4

)

Phone no. & Physical address

Outcome of Contact Trial

Noti-fied face to

face (Y,N)

Previous HIV Test Status HTS Provided RTRI for newly diagnosed HIV

positive contacts Linkage to care & treatment PrEP services cascade for HIV Negative Sero Discordant Couples Adverse Events monitoring

Case

clo

sure

stat

us (

code

1 to

4)

Index MRN/UAN Linked to care (Y,N)

Is CRF completed (Y,N)

Tested for recency (Y,N)

Case Classifica-tion Status 1st Trial 2nd Trial 3rd Trial

Test-ed Be-fore (Y,N)

Prio

r HIV

test

resu

lt (P

/N/I

)

Dura

tion

sinc

e la

st te

st (

in

mnt

h)

HIV Self-test National Algo-rithm

Is s/he Eligi-

ble for Recency testing ? (E, NE)

Is s/he Test-

ed for recency ? (Y,N)

Recency testing

result: Prob-able Recent

(R), Long-term (LT),

Inconclusive (IR)

Date Linked to ART

Date ART

started

UAN of new-ly identified HIV positive

Date

new

HIV

Pos

itive

Con

tact

lin

ked

to IC

T se

rvic

e

If no

t lin

ked

to I

CT (C

ode

1-3)

Assessed for PrEP

(Y, N)

PrEP el-igibility (E, NE)

Started Oral PrEP (Y,N)

Date started

PrEP

Adverse Events for IPV (Y,N)

If Y, AE type ( 1-13)

Linked to aprropriate

service (Y,N)

Region /Zone

Sex (M/F)

ART started (Y/N)Date

Date

Write the Case Classification

Result (C-1, C-2, C3)

Date offered

Date (D/M/Y)

Out

com

e ( 1

- 4)

Date (D/M/Y)

Out

com

e ( 1

- 4)

Date (D/M/Y)

Out

com

e ( 1

- 4) Date HIV

Self-test kit dis-

tributed (D/M/Y)

Date contact

reported self test result

(D/M/Y)

Cont

act H

IV S

elf-t

estin

g re

sult

(R/N

R) Date contact tested for HIV

(D/M/Y)

Cont

act H

IV te

st re

sult

(P/N

/I)

Woreda/Town CBS ID Accepted

Kebele & House Number

Targ

et p

opu-

latio

n gr

oup

( 1-

7)

Date ART Started Initial CBS ID Recency testing result: Probable Recent (R),

Long-term (LT), Incon-clusive (IR)

Date accepted

Phone No. Linked to CBS (Y,N) Eligible for Recen-cy testing (E, NE)

If No, Indicate Why? (1-6)

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

4: Prioritizing Criteria for ICT services (write code) (Col. 4)1. Newly Diagnosed 2. PLHIV with HVL & Adult 3. PLHIV restart ART & Adult 4. PLHIV in Care with STI 5. Enrolled @ PMTCT 6.Key population (Female sex workers) 7. Other (Specify)

If the client don’t accept ICT services, write the reason: (Col. 9)1. No reason 2. No time for elicitation interview 3. Do not believe services are confidential ( Fear of disclosure ) 4.Afraid of intimate partner violence 5. Prefer to go to Other HF for this service 6. Other (Specify)

Contact category (Col. 13)1.Sexual Partner 2. Child, < 15 years 3.Parent of an index child 4. Siblings ( If Index is a child )

Intimate Partner Violence (IPV) risk assessment Outcome (Col. 14) 1. Physical 2. Emotional 3. Sexual 4. No IPV 5. NA Child

INDEX CASE TESTING REGISTERMonth________________Year__________________

Target population group (A-I): (Col. 4)A-FSW B-Long distance truck drivers C-PrisonersD-Mobile Worker/Daily laborer E- OVC F-Partner of PLHIV G-Children of PLHIV H -Other MARPS (Widowed, Divorced, Separated, Re-Married) I- General Population

Index Case Information & Service Provided Elicited Contacts Information & Services Provided

RemarkS.N

Name of the index case

Age

Prio

ritizi

ng C

riter

ia (

1 - 7

)

Date Tested HIV+ If newly diagnosed (1): ICT service

Offered (Y, N)

Name of Index Contacts Elicited Age Sex (M/F)

Con

tact

cat

egor

y (c

ode

1-4)

IPV

Risk

Ass

essm

ent C

ondu

cted

( Y

, N)

IPV

Risk

Ass

essm

ent O

utco

me

(1-5

)

If there is high risk of IPV, is s/he

linked to PGBV care?

(Y,N)

Has the index client

already Disclosed

his/ her HIV status? ( Y,

N,)

N

otific

ation

Pla

n/M

etho

d (C

ode

1 - 4

)

Phone no. & Physical address

Outcome of Contact Trial

Noti-fied face to

face (Y,N)

Previous HIV Test Status HTS Provided RTRI for newly diagnosed HIV

positive contacts Linkage to care & treatment PrEP services cascade for HIV Negative Sero Discordant Couples Adverse Events monitoring

Case

clo

sure

stat

us (

code

1 to

4)

Index MRN/UAN Linked to care (Y,N)

Is CRF completed (Y,N)

Tested for recency (Y,N)

Case Classifica-tion Status 1st Trial 2nd Trial 3rd Trial

Test-ed Be-fore (Y,N)

Prio

r HIV

test

resu

lt (P

/N/I

)

Dura

tion

sinc

e la

st te

st (

in

mnt

h)

HIV Self-test National Algo-rithm

Is s/he Eligi-

ble for Recency testing ? (E, NE)

Is s/he Test-

ed for recency ? (Y,N)

Recency testing

result: Prob-able Recent

(R), Long-term (LT),

Inconclusive (IR)

Date Linked to ART

Date ART

started

UAN of new-ly identified HIV positive

Date

new

HIV

Pos

itive

Con

tact

lin

ked

to IC

T se

rvic

e

If no

t lin

ked

to I

CT (C

ode

1-3)

Assessed for PrEP

(Y, N)

PrEP el-igibility (E, NE)

Started Oral PrEP (Y,N)

Date started

PrEP

Adverse Events for IPV (Y,N)

If Y, AE type ( 1-13)

Linked to aprropriate

service (Y,N)

Region /Zone

Sex (M/F)

ART started (Y/N)Date

Date

Write the Case Classification

Result (C-1, C-2, C3)

Date offered

Date (D/M/Y)

Out

com

e ( 1

- 4)

Date (D/M/Y)

Out

com

e ( 1

- 4)

Date (D/M/Y)

Out

com

e ( 1

- 4) Date HIV

Self-test kit dis-

tributed (D/M/Y)

Date contact

reported self test result

(D/M/Y)

Cont

act H

IV S

elf-t

estin

g re

sult

(R/N

R) Date contact tested for HIV

(D/M/Y)

Cont

act H

IV te

st re

sult

(P/N

/I)

Woreda/Town CBS ID Accepted

Kebele & House Number

Targ

et p

opu-

latio

n gr

oup

( 1-

7)

Date ART Started Initial CBS ID Recency testing result: Probable Recent (R),

Long-term (LT), Incon-clusive (IR)

Date accepted

Phone No. Linked to CBS (Y,N) Eligible for Recen-cy testing (E, NE)

If No, Indicate Why? (1-6)

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

____/____/____ ___/____/___

____/____/____

________/_______/________

___/____/___

____/____/____

Notification Plan (Col. 18) 1. Client 2. Contractual 3. Dual 4. Provider

If not linked to P&FB ICT (Col. 42)1.Referred2. Declined3.Other

Adverse Events Type: (Col. 48)1. Divorce 2. Loss of relationship 3. Loss of support 4. Stigma 5. Job loss 6. Social exclusion 7. Verbal abuse 8. Physical abuse 9. Loneliness 10. Cessation of sexual intercourse 11. Marital discord 12. Taking away access to your children 13. Other (specify)

Case Closure status : (Write code 1 to 4 ) according to each elicited contact outcome: (Col. 50)1. Successful Intervention: Contact notified, HIV status known and linked for appropriate services.2. Intervention complete: Contact notified,HIV status known but not linked to appropriate services3. Intervention partially completed: Contact notified, but HIV status unknown (e.g. Declined P&FB ICT services)4. Intervention incomplete: Contact was not notified (e.g. Out of jurisdiction, unable to locate)

INDEX CASE TESTING REGISTER

Health Center/Clinic / Hospital Post Exposure To HIV Prophylaxis

(PEP) Followup Register


SN Datum Comments1 Serial number A sequential No assigned to patients up on registration (Example- 1, 2, and 3) fore letter Identification.2 Reporting Date Use Ethiopian Calendar and a format of DD/MM/YYY to register when patient enrolled in PEP service.

3 Exposed Person MRN Unique individual identifier used for medical information folder, for HC and Hospital and for the other sites it is card number.

4 Age Write the clients Age in year5 Sex M=Male, F=Female

6 Occupation Enter the code given for the current occupation of the exposed person 1. Physician 2. Health officers 3. Nurse 4. Health assistance 5. Laboratory professionals 6. Cleaner 7. Sanitarian 8. Other (specify).

7 Department(Case Team) Enter the cod given here for the department or case team in which the client works (1. Labor ward 2. Emer-gency 3. Regular OPD 4. Inpatient 5. Operation room 6. Other (specify) for occupational exposures.

Exposure (8-11)8 Exposure Duration Write the time from time of exposer to the time the exposed person appeared for the PEP service in hours.

9 Exposure Type Entere the code given for the different types of exposure 1. Occupational 2. Sexual assault (Rape) 3. Other non Occupational (Specify).

10 Source of Exposure Write the codes given 1. Needle stick Injury 2. Skin injury with Sharps 3. Blood and products splash 4. Potentially infectious body fluids 5. Rape 6. Other (specify).

11 Exposure Code

Write the exposure code type among the lists provided : EC1. Mucous membrane & small drops EC2. Mucous membrane& Large volume(several drops) OR percutaneous exposure and less severe( Eg.Solid nnedle,Superficial ) EC3. Percutaneous exposure and more severe

Baseline HIV Status(12-13)

12 Source person Write the HIV status of source person : “P” for reactive or “N “for Non-reactive depending or “UK “for unknown status (not tested).

13 Exposed Person Write the HIV status of Exposed Person: “P” for reactive or “N “for Non-reactive depending or “UK “for unknown status (not tested).

PEP Provision(14-16)

14 Eligible If the client is Eligible for PEP write Y to say Yes , if the client is not Eligible for PEP write N indicating NO.

15 Time b/n Exposure and PEP (in hours) Write the spent from time of exposure to the initiation of the ARV regimen in hours.

16 PEP Regimen Write the PEP drug regimen code: 1.(AZT)TDF+3TC+DTG (TLD) 2.(AZT)TDF+3TC+EFV (TLE) 3.(AZT)TDF+3TC+LPV/r 4. (AZT)TDF+3TC+ATV/r

Exposed Person Followup (17-22)

17 Adherence (17-18) Write adherance at 2wks and 4 wks ; write “G” for a person with good adherence “F” for faire and “P” for Poor.

19 Side effect Write a side effect of ARV drugs the exposed person may develops in words.

20-22 Final HIV Status Write Final Post PEP HIV status of exposed person: Write” P” for reactive or “N” for Non-reactive depending

or “UK “for unknown status (if not tested). For result at 6 weeks, 3 months and 6 months.

23 Remark Use the remark column to document Events like lost, stopped, linkage to HIV care and other findings as applicable.

INSTRUCTION FOR PEP REGISTER

Register (HC/Clinic/Hospital- PEPReg) kept in ARTroom /KP Clinic, and completed by the ART data clerk, based on PEP facility record forms and tally sheets.Location information to be completed at front of register:

Write month and year (EC) at top of page. Region Write the region where the ART center with PEP Service is locatedWoreda / Sub-City Write the woreda/sub-city where the ART center with PEP Service is locatedName of Health Facility Write the name of the health facility where the ART center with PEP Service is located

Exposure Baseline HIV Status PEP Provision Exposed Person Follow up

Se-rial. No

Date of Reporting(DD/MM/YY)

Exposed Person MRN Age Sex

(M/F)

Occu

patio

n( 1-

3)

Depa

rtmen

t (1-

6)

Dura

tion(

Hrs)

Type

(1-3

)

Sour

ce o

f ex

posu

re

(1-6

)

Expo

sure

Co

de(E

C1,E

C2,E

C3)

Sour

ce P

erso

n(P/

N/UK

)

Expo

sed

Pers

on(P

/N/

UK)

Elig

ible(

Y,N) Time

between Expo-

sure and PEP(in

hrs)

PEP Regi-men(1-4)

Adhrence(P,F,G)

Side

Effe

ct Final HIV Status(P.N,Uk) Remark

2weeks 4 weeks 6Weeks 3month 6Month

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Count

Occupational

Sexual violence

Other Non-occupational

Post Exposure To HIV Prophylaxis (PEP) Followup Register

Occupation : (6) 1. Physician 2. Health officers 3. Nurse 4. Health assistance 5. Laboratory professionals 6. Cleaner 7. Sanitarian 8. Other (specify).

Department : (7) 1. Labor ward 2. Emergency 3. Regular OPD 4. Inpatient 5. Operation room 6. Other (specify)

Exposure Type :(9)1. Occupational2.Sexual Viloence 3. Other Non- occupational

Source of Exposure : (10)1. Needle stick Injury 2. Skin injury with Sharps 3. Blood and products splash 4. Potentially infectious body fluids 5. Rape 6. Other (specify).

Exposure Code : (11)EC1. Mucous membrane & small drops EC2. Mucous membrane& Large volume(-several drops) OR percutaneous exposure and less severe( Eg.Solid nnedle,Superficial)EC3. Percutaneous exposure and more severe

PE Regimen:(16)1.(AZT)TDF+3TC+DTG (TLD) 2.(AZT)TD-F+3TC+EFV (TLE) 3.(AZT)TDF+3TC+LPV/r 4. (AZT)TDF+3TC+ATV/r


Health Centre /Clinic/Hospital PrEP Register

S. N Datum Comments

1. Serial number write sequential number in the row column

2. PrEP start date Write the date client started PrEP as E.C. (DD/MM/YY)

3. MRN/UIC Unique individual identifier used on medical information folder, for Public HC/ hospital and UIC for drop-in center

4. Name in full (individual, father, grandfather) Write the patient’s first name in the upper space and father’s and grandfather’s name in the lower space

5. Age Write the clients Age in year

6. Sex M=male, F=Female

7 and 8 Target groupsTick under column 6 if the client is HIV negative discordant couples or

Tick under column 7 if the client is FSW

9Client’s woreda/kebele/Phone number/House number

Write Client’s woreda or Kebele in the above space and clients’ phone number or house number in the lower space

Initial Visit

10 HIV Test date Write the initial date a client tested in the above space and HIV test result in the lower space P=positive, N=Negative

Date client received results Write the date client received HIV test results as E.C. (DD/MM/YY)

11Creatinine (eGFR)

Write the estimated eGFR result (optional)

12 STI Screening with SyndromeWrite ‘Y’ if the client is screened for STI or ‘N’ for if the client is not screened for STI in the above space and if the client is screened positive. write code (STI syndromes: U=Urethral discharge / G=Genital ulcers / V=Vaginal discharge / L=Lower abdominal pain / S=Scrotal swelling / I=Inguinal bubo / O=Other-specify) in the lower space

13 Hepatitis B surface Antigen test Write ‘Y’ if the client is tested or ‘N’ if the client is not tested in the above space and write ‘P’ if the test result is positive or ‘N’ if the test result is negative

14 Pregnancy statusWrite ‘P’ if the client is pregnant or ‘NP’ if the client is not pregnant or NA if Not applicable in the above space and if the client is not pregnant and using FP Method write the Family planning code (FP= On Family Planning (enter code):1= Condoms, 2= Oral contraceptive pills, 3=Injectable/implantable hormones, 4=Diaphragm/cervical cap, 5=Intrauterine device, 6=Vasectomy/tubal legation, 7= Abstinence (no sex) in the lower space

15 Number of Tablets Write number of tablets prescribed

Follow up Visit -1

16 Date Write follow up date as E.C. (DD/MM/YY)

17 HIV Re-testing result Write the date HIV retested and HIV test result ‘P’ for positive or ‘N’ for negative under Date HIV retested and HIV test result column

18 Side effect Write the code of side effects as ( A= Abdominal pain/ S=Skin rash/ Nau=Nausea/ V=Vomiting/ D=Diarrhea/ F=Fatigue/ H=Headache/ L = Enlarged lymph nodes and/ R= Fever / O=Other-specify)

19 Adherence Write ‘G’ for good adherence if the client missed 4 or less than 4 tablets or ‘P’ for poor adherence if client missed more than 5 and above tablet or dose in one month

20 Follow up StatusIf the client is on treatment write number of tablets prescribed, if transferred out other facility write T0, if the client died while on treatment write ’D’ and if the client lost from follow up for more than one month write LTFU

21 STI Screening with SyndromeWrite ‘Y’ if the client is screened for STI or ‘N’ for if the client is not screened for STI in the above space and if the client is screened positive in the lower space. write code (STI syndromes: U=Urethral discharge / G=Genital ulcers / V=Vaginal discharge / L=Lower abdominal pain / S=Scrotal swelling / I=Inguinal bubo / O=Other-specify)

22-68 For Follow up visit- 2 and above use the instruction commented under Follow up visit -1(serial number 16-21)

69 Stopped PrEPWrite the date client stop PrEP as E.C. (DD/MM/YY) in the above space and write the code reasons for stopped (H=Tested HIV+/R=No longer at substantial risk/S=side effects/Specify any other reasons) in the lower space

INSTRUCTION FOR PrEP REGISTERRegister (HC/Clinic/Hospital- PrEPReg) kept in ARTroom /KP Clinic, and completed by the ART data clerk, based on PrEP facility record forms and tally sheets.

Location information to be completed at front of register: Write month and year (EC) at top of page.

Region Write the region where the ART center with PrEP Service is located

Woreda / Sub-City Write the woreda/sub-city where the ART center with PrEP Service is located

Name of Health Facility Write the name of the health facility where the ART center with PrEP Service is located

PrEP Register

Side effects: A= Abdominal pain, S=Skin rash, Nau=Nausea, V=Vomitin,D=Diarrhea, F=Fatigue/,H=Headache,L = Enlarged lymph nodes and, R= Fever ,O=Other-specifyFamily Planning (enter code): (Col. 14) 1= Condoms, 2= Oral contraceptive pills, 3=Injectable/implantable hor-mones, 4=Diaphragm/cervical cap, 5=Intrauterine device, 6=Vasectomy/tubal legation, 7= Abstinence (no sex)

STI syndromes: U=Urethral discharge ,G=Genital ulcers , V=Vaginal discharge , L=Lower abdominal pain , S=Scrotal swelling . I=Inguinal bubo , O=Other-specifyFollow up status :-If The client is on treatment write number of tablet ,TO=Transfer out ,LTFU=lost ,D=Dead

Adherence: <=4 means good and 5 + mneans poor adherence

S.NO PrEP start-ed Date MRN/ UIC

Name

Age (In years)

Sex (M /

F)

Targ

et P

opul

ation

Wor

eda/

Kebe

le Initial visit Status Follow - Up visit 1 Follow - Up visit 2 Follow - Up visit 3 Follow - Up visit 4 Follow - Up visit 5 Follow - Up visit 6 Follow - Up visit 7 Follow - Up visit 8 Stopped PrEP

Dat

e H

IV

test

ed

Crea

tinin

e (e

GFR

)

STI screen-

ing (Y/N)

Hepatitis B Test

(HBsAg) done (Y/N)

Preg

nanc

y te

st re

sult

(P/N

/NA

)/

Num

ber

of ta

blet

s (T

DF,

3TC)

Visit date

Dat

e H

IV

Re-t

este

d

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Date

Father’s and Grand-father’s name

sero - dis-cordant couples

(ü) FSW

(ü)

Tele

phon

e #/

HNo

# /

Resu

lt:

(Pos

. /

Neg

.)

STI S

yn-

drom

e Test Result (P/N)

FP meth-od (see codes)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code) Re

ason

s (s

ee c

odes

)

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69

PrEP Register

Stopped PrEP reasons: H=Tested HIV+, R=No longer at substantial risk,S=side effects, Specify any other reasons

S.NO PrEP start-ed Date MRN/ UIC

Name

Age (In years)

Sex (M /

F)

Targ

et P

opul

ation

Wor

eda/

Kebe

le Initial visit Status Follow - Up visit 1 Follow - Up visit 2 Follow - Up visit 3 Follow - Up visit 4 Follow - Up visit 5 Follow - Up visit 6 Follow - Up visit 7 Follow - Up visit 8 Stopped PrEP

Dat

e H

IV

test

ed

Crea

tinin

e (e

GFR

)

STI screen-

ing (Y/N)

Hepatitis B Test

(HBsAg) done (Y/N)

Preg

nanc

y te

st re

sult

(P/N

/NA

)/

Num

ber

of ta

blet

s (T

DF,

3TC)

Visit date

Dat

e H

IV

Re-t

este

d

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Visit date

Dat

e H

IV

Re-t

este

d

Resu

lt (P

/ N

)

Side

effe

cts

(s

ee c

odes

)

Adh

eren

ce (G

/P)

Follo

w u

p st

atus

STI

scre

enin

g

Date

Father’s and Grand-father’s name

sero - dis-cordant couples

(ü) FSW

(ü)

Tele

phon

e #/

HNo

# /

Resu

lt:

(Pos

. /

Neg

.)

STI S

yn-

drom

e Test Result (P/N)

FP meth-od (see codes)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code)

Resu

lt: (P

os.

/ N

eg.) Result

(write code) Re

ason

s (s

ee c

odes

)

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69


Health Centre /Clinic/Hospital Clinical Care Tally

Sex

Cate

gory

TB_Screening for TPT Initiation TPT Completion CxCa Screeening

CxCa Treatment Nutritional Screening Received therapeutic or supplementary food

Newly enrolled ARTclients screened for TB

Priously on ART & screened for TB # of ART pts that start TPT # who initiated TPT 12 months before # who completed TPT Screening Type Screening Results

# Screened Screened Positve # screened Screened

positive INH 3HP 3HR INH 3HP 3HR INH 3HP 3HR HPV VIA HPV: +ve HPV: -ve VIA: Normal VIA: Precan-cerous

VIA: Suspect-ed Ca Cryotherapy LEEP Thermocoagu-

lation Normal Mild MAM SAM Overwieght MAM SAM

tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count

Male

<15

15+

Fe-male

<15

15-19:

20-24:

25-29

30-49

50+

Total

Clinical Care Tally


Health Centre /Clinic/Hospital Currently on ART by Regimens and

DSD Tally

Age Category (yrs)

Number of PLHIVs currently on ART, by age and sex and regimen category Number of PLHIV newly started on ART Viral load test

Male Female Male Female Male Female1st line 2nd line 3rd line 1st line 2nd line 3rd line tested suppressed Low level viremia High Viral Load tested suppressed Low level viremia High Viral Load

Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count

<1

1-4

5-9

10-14

15-19

15-19 pregnant

20-24

20-24 pregnant

25-29

25-29 pregnant

30-34

30-34 pregnant

35-39

35-39 pregnant

40-44

40-44 pregnant

45-49

45-49 pregnant

50+

Enrolled on DSD

Male Female15-19 years 20-24years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ years 15-19 years 20-24years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ years

tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count

3MMD ASM(6MMD)FTARCAGPCADDSD for AdolesentDSD for KPDSD for MCHDSD for AHDOthers Total

Terminated from DSD

3MMD ASM(6MMD)FTARCAGPCADDSD for AdolesentDSD for KPDSD for MCHDSD for AHDOthers Total

Currently On ART by Age, Sex, Regimens and DSD Tally

Currently On ART by Age, Sex, Regimens and DSD TallyFacility: Year: Month: _

REGIMENMale Female Male Female

<1 years 1-4years 5-9 years 10-14 years 15-19 years <1 years 1-4years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49years 50+ years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49years 50+ yearstally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count tally count

CHILD REGIMENChild first line 4d = AZT+3TC+EFV4e = TDF+3TC+EFV4f = AZT +3TC + LPV/r

4g = ABC + 3TC + LPV/r

4i = TDF + 3TC + DTG4j = ABC + 3TC + DTG4K = AZT + 3TC + DTG4L = ABC + 3TC + EFV4h = Other specifyChild second line5e=ABC+3TC+LPV/r5f=AZT + 3TC + LPV/r5g=TDF + 3TC + EFV5h=ABC + 3TC + EFV5i= TDF + 3TC+LPV/r5m= ABC+3TC+DTG5n= AZT+3TC+DTG5o=TDF+3TC+DTG5j= Other specifyChild third line6c= DRV/r + DTG + AZT +3TC6d = DRV/r + DTG +TD-F+3TC6f = DRV/r+DTG+AB-C+3TC6g =DRV/r+AB-C+3TC+EFV6h=DRV/r+AZ-T+3TC+EFV6e = Other specifyADULT REGIMENAdult first line

1d = AZT - 3TC - EFV 1e = TDF - 3TC - EFV

1g = ABC + 3TC + EFV

1j = TDF + 3TC + DTG

1K = AZT + 3TC + DTG

1i = Other specifyAdult second line

2e= AZT +3TC +LPV/r 2f =AZT+3TC +ATV/r2g=TDF + 3TC+-LPV/r2h= TDF + 3TC + ATV/r2i= ABC + 3TC+ LPV/r2j = TDF + 3TC + DTG

2K = AZT + 3TC + DTG

2l= Other specifyAdult Third Line

3a = DRV/r+DTG+AZ-T+3TC3b = DRV/r+DTG+TD-F+3TC3c= DRV/r+AB-C+3TC+DTG3e =DRV/r+TD-F+3TC+EFV3f= DRV/r+TAZ-T+3TC+EFV3d = Other specify

Total


Health Centre /Clinic/Hospital HIV Testing Service Tally Sheet

Target population Category

Male Female<1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ <1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ Years

HIV Test Result Received

Positive Result Received















































Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count(2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15 (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (‘39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65) (66) (67) (68) (69) (70) (71) (72) (73) (74) (75) (76) (77) (78) (79) (80) (81) (82) (83) (84) (85) (86) (87) (88) (89) (90) (91) (92) (93) (94) (95) (96) (97)

Female Sex workers

Long distance drivers

Prisoners

Mobile workers/daily laborers

OVC

Partners of PLHIV

Children of PLHIV

Other MARPS (Widowed, Divorced, Separated, Re-Married)

General Population

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per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

HTS (HIV Testing Service) TALLY SHEETService Delivery ___________________ (Write VCT or PITC)________________________

Target population Category

Male Female<1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ <1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ Years

















































Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count(2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15 (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (‘39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65) (66) (67) (68) (69) (70) (71) (72) (73) (74) (75) (76) (77) (78) (79) (80) (81) (82) (83) (84) (85) (86) (87) (88) (89) (90) (91) (92) (93) (94) (95) (96) (97)

Female Sex workers

Long distance drivers

Prisoners

Mobile workers/daily laborers

OVC

Partners of PLHIV

Children of PLHIV

Other MARPS (Widowed, Divorced, Separated, Re-Married)

General Population

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per-formed

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per-formed

posi-tive

per-formed

posi-tive

per-formed

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per-formed

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posi-tive

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posi-tive

per-formed

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per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

per-formed

posi-tive

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per-formed

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per-formed

posi-tive

per-formed

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per-formed

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per-formed

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per-formed

posi-tive

HTS (HIV Testing Service) TALLY SHEET Woreda:______________ Facility:__________________________ Year:_____________ Month:___________________

Start Date_______________ End Date:________________


Health Centre /Clinic/Hospital ICT Tally

ICT Cascade

Male Female

Total

<1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ <1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+

Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count

Offered

Accept-ed

Elicited

Tested

New positives

New negative

Known positive

Woreda:______________ Facility:__________________________ Service Delivery Point: _________________________ Year:_____________ Month:___________________Start Date_______________End Date:________________

ICT Tally

ICT Cascade

Male Female

Total

<1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+ <1 years 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50+

Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count

Offered

Accept-ed

Elicited

Tested

New positives

New negative

Known positive

ICT Tally


Health Center/ HospitalDiseases Tally

Disease Name (ESV-ICD 11) ESV-ICD 11 code

Female Male<1 yr 1 - 4 yrs 5 - 14 yrs 15 – 29 yrs 30 – 64 yrs >=65 yrs <1 yr 1 - 4 yrs 5 - 14 yrs 15 – 29 yrs 30 – 64 yrs >=65 yrs

Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count

Diseases Tally

HSSContent / Home

Hospital Gender Based Violence Register

_______ _________________ ______________ ___________ __________ Region Sub-city/Woreda Health Facility Name Begin Date End Date

Description of the patients’ information filled on main part of registerCol. No Datum Description

(1) S/NoEnter sequentially number starting from 1 until the budget year end and start again from 1 at the first day of new

budget year

(2) Date Write the date of the GBV survivor visited the health facility, written as (EC) Day / Month / Year (DD/MM/YY)

(3) MRN Write unique individual identifier Medical Record Number used on medical information folder, for HC and hospital.

(4) Survivor’s fill Name Write the full name (Given, middle and last) of the GBV survivor

(5) AgeWrite age of patient (if it is under 1 month enter in days, if it is under 5 year, enter in month and enter in year if it is

above 5 year old)

(6) Sex Write sex of patient as M for Male and F for Female

(7) Woreda Write the name of the woreda where the survivor comes from

(8) Kebele Write the name of the kebele where the survivor comes from

(9) Telephone Write the telephone number (10 digit) of the survivor or close family

(10) Marital status Write the marital status of the GBV survivor as the code given at the bottom of the page. Use code 1. for single, 2 for married, 3 for divorced and 4 for widowed

(11) Education level Write the educational levels of the GBV survivor as the code given the bottom of the page. Use code 1. for Illiterate, 2 for Elementary, 3 for secondary/high school and 4 for College/University

(12) Key Population Identify the GBV survivor’s classification according to the key population category and write the code. Code 1 for CSW (Commercial sex Workers), 2 for prisoners, 3 for OVC (Orphan and Vulnerable children), 4 for IDP (Internally displaced people), 5 for people with disability and 6 for others including the general population

(13) The perpetrator Write the perpetrator based on the category stated at the bottom of the page. Accordingly write 1 if the perpetrator is a family member, 2 if intimate partner and 3

(14)Type of Violence (Sexual, Physical, Psychological, Mixed)

Write the type of the violence as categorized at the bottom of the page. Use code 1 if the violence is sexual, 2 if it is physical, 3 if psychological and 4 if mixed (a mix of any of the three).

(15) # of days after incident Write the number of day in number, example 8, since the incident

(16) Past GBV history Write 1 if there is past history which happened by the same person, 2 if there is past history which happened by a different person and 3 if there is no past history of GBV

(17) Fresh tear/ Bruise etc Write yes if the survivor has any fresh tear, bruise or any other evidence of damage (Vaginal, anal etc) and write No if there is none.

(18) Types of Rape code (If Rape)If the violence was rape, the write the type of rape as coded in the bottom of the page. Write 1 if it is attempted rape, 2 if Acquaintance Rape, 3 if Forced Rape and 4 if other

(19) Pregnancy Test Write ‘Positive’ if the pregnancy test is positive, ‘Negative’ if the test is negative and ‘Not done’ if pregnancy test is not done.

(20) VDRL Write ‘Positive’ if the VDRL test is positive, ‘Negative’ if the test is negative and ‘Not done’ if VDRL test is not done.

(21) HIV Test Write ‘Positive’ if the HIV test is positive, ‘Negative’ if the test is negative and ‘Not done’ if the HIV test is not done.

(22) Serum For HBs AgWrite ‘Positive’ if the Serum for HBs Ag test is positive, ‘Negative’ if the test is negative and ‘Not done’ if Serum for HBs Ag is not done.

(23) Standard Treatment of injuries Write ‘YES’ if standard treatment is given for injuries is given, ‘No’ if standard treatment is given for injuries is not given and ‘NA’ if injury treatment was not applicable to the survivor

(24) First- line Support given (yes, No) Write ‘YES’ if first line support is given and ‘No’ if not given

(25) Emergency ContraceptiveWrite ‘YES’ if emergency contraceptive is given, ‘No’ if not given and ‘NA’ if emergency contraceptive provision was not applicable to the survivor

(26) PEP Write ‘YES’ if post exposure prophylaxis (PEP) is given, ‘No’ if not given and ‘NA’ if post exposure prophylaxis (PEP) provision was not applicable to the survivor

(27) STI Write ‘YES’ if STI test is done, ‘No’ if not done and ‘NA’ if STI test is not applicable to the survivor

(28) HB Vaccine Write ‘YES’ if HB vaccine is given, ‘No’ if not given and ‘NA’ if HB vaccine provision is not applicable to the survivor

(29) Referral to other servicesWrite the referral service status according to the list at the bottom of the table. Write code 1 if survivor is referred for legal service, 2 if referred for psychological support, 3 if ART (Chronic care), 4 if survivor was referred for other services and 5 if referral service was not required.

(30) Remark Write if there is any remark

Instruction for Gender Based Violence (GBV) RegisterInformation filled at front page of register

Region Write region name where the facility is located

Zone/Sub city /Woreda Write Zone/Sub-City /Woreda name where the facility is located.

Facility Name Write the name of the health facility where the service was provided

Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register end date Write the date of the last entry in the register, written as (EC) Day / Month /Year (DD/MM/YY)

S.NDate

(DD/MM/YY)

MRN Survivor’s Full Name AgeSex-

(M/F)

Contact Adress

Marital status

*

Edu-cation Level*

Key * popula-

tion?

The Perpe-trator*

Type of Vio-lence (Sexual,

Physical, Psychological,

Mixed)

# of days after

incident

Past GBV history *

If Sexual (History, Physical exam and laboratory tests)

Stan

dard

Tre

atm

ent o

f in

juri

es (Y

es, N

o, N

A)

Firs

t- li

ne S

uppo

rt g

iven

(y

es, N

o)Em

erge

ncy

Cont

race

ptive

(Y

es,N

o, N

A)

PEP

(Yes

,No,

NA

)

STI

(Yes

,No,

NA

)

HB

Vacc

ine

(Yes

, No,

NA

)

Refe

rral

to o

ther

ser

vice

s

Remark Woreda Kebele Telephone

Fres

h te

ar/

Brui

se

etc

(Cod

e=Ye

s,N

o)

Type

s of

Rap

e co

de

(If R

ape)

Preg

nanc

y Te

st (P

os,

Neg

, Not

don

e)VD

RL (P

os, N

eg, N

ot

done

)H

IV T

est (

Pos,

Neg

, N

ot d

one)

Seru

m F

or H

Bs A

g (P

os, N

eg, N

ot d

one)

(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) (26) (27) (28) (29) (30)

1

2

3

4

5

6

7

8

9

10

11

Count

Sexual ViolencePhysical ViolencePsychological ViolenceMixed

Region ________________ Woreda ______________________ Name of Health Facility _______________________

* KP = Key Population (Col. 12)1. CSW (Commercial sex Workers)2. Prisoners 3. OVC4. IDP5. People wit disability6. Others

Types of Rape code (Col. 18)1. Attempted Rape 2. Acquaintance Rape 3. Forced Rape 4. Other

Marital status Code (Col. 10)1. single 2. Married 3. Divorced 4. windowed

Education (Col. 11)1. Illiterate 2. Elementery 3. secondary/high school4. college/ university

The Perpetrator (Col. 13)1.Family member 2. Intimate partners 3. Stranger

Past history of GBV (Col. 16)1. By same person2. By differnet person3. No past history

Referral to other services code (Col. 29)1. Legal2. Psychosocial support 3. ART( Chronic care)4. Other5. No referral was needed

Gender Based Violence Registration Book

_______ ___________ ______________ ________ ________

Region Zone/Sub city/Woreda Health Facility Name Begin Date End Date

Health center/Clinic/HospitalDrug Dispensing Register




Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

Register end date Write the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

This register is kept at Dispensing unit

Information filled at front page of register

Description of the patients’ information filled on main part of registerColumnNumber

Datum Description

(1) S/NoEnter sequentially number starting from 1 until the budget year end and start again from 1 at the first day of new budget year

(2) MRN Write unique individual identifier Medical Record Number used on medical information folder, for HC and hospital.

(3) Patient Name Write name of the Patient /Clients

(4) AgeWrite age of patient (if it is under 1 month enter in days, followed by “0“ if it is under 5 year followed by “M“, enter in month and enter in year if it is above 5 year old)

(5) Sex Write sex of patient as M for Male and F for Female

(6) Diagnosis (ESV_ICD11)Write the diagnosis based on Ethiopia Simplified Version International Classification of Disease (ESV_ICD11) as it appears on hand book (do not abbreviate)

(7) Drugs prescribedWrite the name of all drug prescribed per patient in one cell separated by coma. E.g. Amoxicillin 500mg, Paracetamol 500mg…

(8) All dispensedEnter ‘1’ only if all the prescribed drugs are dispensed and enter ‘0’ if one or more medicines are not dispensed.

(9) AntibioticsEnter ‘1’ only if at least one antibiotics has been prescribed (except antiprotozoal, anti-helminthic, or anti-tuberculosis) and ‘0’ if no antibiotics prescribed per individual patient

(10) Total prescribed Write total number of drugs prescribed per individual patient

(11) # on FSML Write the number of drugs prescribed from facility specific medicine list (FSML)

(12) Remark Write anything regarding the patient or other related to medicine

Instruction for Dispensing Register

S.N MRN Patient Name Age

Sex

(M/F

)

Diagnosis (ESV_ICD11) Medicines PrescribedTotal # of Pre-scribed Meds

# of Meds from

*FSML

All dispensed (1,0)

Antibiotics (1,0)

Remark

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

Count/Sum

FSML: Facility Specific Medicine List

Health Facility Dispensing Registration BookRegion___________________Woreda _________________Name of Health Facility___________________

ESV_ICD11 Code


Data Quality and Performance monitoring logbook Health center Level

Health Center department level report timeliness and completeness monitoring form

Datum Description

S/No write serial number as 1, 2, 3

Department/Ward write department or ward name report recived from

# of expected data element Enter number of expected data element from departments

# of data element completed Enter number of data elements filled and received from the department

Report received date Write the date report received from wards or department

Name and signature Write name and signature of the person issued the report

Remark Write any thing regarding the department or data

Health Center level report timeliness and completeness monitoring form

S/ No write serial number as 1, 2, 3

Health Post Name Write name of health post expected to report

OPD report received date write the date OPD report received

Monthly service report received date write the date monthly Service report received

Quarterly service report received date write the date quarterly Service report received

Yearly service report received date write the date yearly Service report received

Lot Quality Assurance Sampling working Template


Reportable data element enter selected reportable data elements based on protocol

count on register enter the counted data value from register

count on Tally Sheet enter the counted data value from tally sheet

count on report enter the counted data value from report

Match (write Yes or No) Write yes if data from register, talley, report is consistent/match or No if it is doesn’t match/inconsistent

Intera data element inconsistency checksheet


Data elemenets with inconsistency write the data elements with inconsistency get from DHIS 2 data validation output

Possible causes for this inconsistency write possible causes for this inconsistency after discussion with PMT or finding from assessment

actions taken Write actions taken as corrected or not corrected

Way forward write the suggested points for future improvement

Instruction for data Quality and performance monitoring logbook

Month--------------------------------------------------Year-----------------------------------------------E.C

S/N Department/Ward # of Expected Data Element

# of Data Element Completed

Report Received Date Name and signature Remark

Total expected report from departmentsTotal received report during the given period from departmentsTotal report received timelyOverall report content completeness in %

Data quality monitoring logbook Health Center Department level report Timeliness and Completeness monitoring form

Health Center Name--------------------------------------

PHCU: ___________________ Woreda: _________________ Zone: __________________ Region: ______________________

Month _____________________________ Year _____________________ E.C

S/No Health Post Name Disease Report Received Date Monthly Service Report Received Date

Quarterly Service report Received date

Yearly Service Report Received Date

Total expected report from health Posts

Total received reported during the given period from health Posts

Total report received timely

Data Quality Monitoring logbookHealth Center Report Completeness and Timeliness Monitoring Sheet of Catchment Health Posts

Lot Quality Assurance Sampling (LQAS)working TemplateService Report

S/N Reportable Data Element Count on Register

Count on Tally

Count on Report

Match (write Yes or

No)

Signature of PMT members involved on LQAS 1. Name------------------------------------------------------------Department------------------------------ signature..................... 2. Name------------------------------------------------------------Department------------------------------ signature..................... 3.Name------------------------------------------------------------Department------------------------------ signature..................... 4. Name------------------------------------------------------------Department------------------------------ signature..................... 5. Name------------------------------------------------------------Department------------------------------ signature..................... 6. Name------------------------------------------------------------Department------------------------------ signature..................... 7. Name------------------------------------------------------------Department------------------------------ signature..................... 8. Name------------------------------------------------------------Department------------------------------ signature..................... 9. Name------------------------------------------------------------Department------------------------------ signature..................... 10. Name------------------------------------------------------------Department------------------------------ signature...................

1

2

3

4

5

6

7

8

9

10

11

12

Total Yes

LQAS score

Note: LQAS should be done for both service and disease report

Decision Rules for sample Sizes of 12 and Coverage Targets /Average of 20-95%

Sample Size

Average Coverage (baselines)/Annual Coverage Targets (Monitoring and Evaluations)

Less than 20% 20% 25% 30% 35% 40% 45% 55% 60% 65% 70% 75% 80% 85% 90% 95%

12 N/A 1 1 2 2 3 4 5 6 7 7 8 8 9 10 11

Date----------------------------- Month------------------------------ Year-----------------------

Facility Name-------------------------------------------------------- Woreda-------------------------- Zone--------------------- Region------------------

Lot Quality Assurance Sampling (LQAS) working TemplateOPD Report


Count on Tally

Count on Report

Match (write Yes or

No)


1

2

3

4

5

6

7

8

9

10

11

12

Total Yes

LQAS score



Sample Size


Less than 20% 20% 25% 30% 35% 40% 45% 55% 60% 65% 70% 75% 80% 85% 90% 95%

12 N/A 1 1 2 2 3 4 5 6 7 7 8 8 9 10 11

Date----------------------------- Month------------------------------ Year-----------------------


Lot Quality Assurance Sampling (LQAS)working Template IPD Report


Count on Tally

Count on Report

Match (write Yes or

No)


1

2

3

4

5

6

7

8

9

10

11

12

Total Yes

LQAS score

Date----------------------------- Month------------------------------ Year-----------------------




Sample Size


Less than 20% 20% 25% 30% 35% 40% 45% 55% 60% 65% 70% 75% 80% 85% 90% 95%

12 N/A 1 1 2 2 3 4 5 6 7 7 8 8 9 10 11

Month--------------------------------Year------------------------------------------S/N Data Elemenets with Inconsistency Possible Causes for this Inconsistency Actions Taken Way Forward

1

2

3

4

5

6

7

8

9

10

11

12

Note: Data elements with inconsistencies are exported or printed from DHIS 2 database and presented for PMT members then write it on the above template or attached on this log book

Intera Data Element Inconsistency Checksheet

PMT Meeting Minute BookDate:____________________________Time:__________________________ Participants:S/N Full Name Department Position Signature

1

2

3

4

5

6

7

8

9

10

Agenda:Performance Monitoring Template

S.No Selected indicator Current Month Performance

Previous month performance

Cummulative to date Performance Target

Previous year the same reporting period

performance

Investigation need (Yes,No) Remark

1

2

3

4

5

6

7

8

9

10

11

12

Discussion on the Performance Finding

Discussion on the Data Quality

Prioritizing the Problems

Indicator Magnitude of the Problem*

Seriousness of the Problem*

Community Con-cern*

Feasibility of Inter-vention* Total score

*Point System: 3-High, 2-medium, 1-low

Action Plan

Indicators to be investigated Main Reason(s) Possible Cause(s) Solutions/Action Points Responsible Per-son/Section Time


Data Quality and Performance monitoring logbook Hospital Level

Hospital department level report timeliness and completeness monitoring formDatum Description

S/No Write serial number as 1, 2, 3

Department/Ward Write department or ward name report recived from

# of expected data element Enter number of expected data element from wards or departments

# of data element completed Enter number of data elements filled and received from wards or department

Report received date Write the date report received from wards or department

Name and signature Write name and signature of the person issued the report

Remark Write any thing regarding the department or data

Lot Quality Assurance Sampling working TemplateS/No Write serial number as 1, 2, 3

Reportable data element Enter selected reportable data elements based on protocol

Count on register Enter the counted data value from register

Count on tally Sheets Enter the counted data value from tally sheet

Count on report Enter the counted data valuet from report

Match (write Yes or No) Write yes if data from register, tally and report is match/consistent or No if it is doesn’t match /inconsistent

Intera data element inconsistency checksheetS/No Write serial number as 1, 2, 3

Data elements with inconsistency Write the data elements with inconsistency get from DHIS 2 data validation output

Possible causes for this inconsistency Write possible causes for this inconsistency after discussion with PMT or finding from assessment

Actions taken Write actions taken as corrected or not corrected

Way forward Write the suggested points for future improvement

Instruction for data quality and performance monitoring logbook

S/N Department/Ward # of expected data element

# of data element completed Report received date Name and signature Remark

Total expected report from departments

Total received report during the given period from departmentsTotal report received timelyOverall report content completeness in %

DATA QUALITY MONITORING LOGBOOK FOR HOSPITALDepartment Level Report Timeliness and Completeness Monitoring Form

Hospital Name---------------------------------------------------------- Month--------------------------Year------------------------E.C


Count on Tally

Count on Report

Match (write Yes or

No)


1

2

3

4

5

6

7

8

9

10

11

12

Total Yes

LQAS score

Lot Quality Assurance Sampling working Template Service Report

Date----------------------------- Month------------------------------ Year-----------------------

Hospital Name------------------------------------------------- Woreda-------------------------- Zone--------------------- Region--------------------------------



Sample Size


Less than 20% 20% 25% 30% 35% 40% 45% 55% 60% 65% 70% 75% 80% 85% 90% 95%

12 N/A 1 1 2 2 3 4 5 6 7 7 8 8 9 10 11

Lot Quality Assurance Sampling working Template OPD Report

Hospital Name--------------------------------------- Woreda-------------------------- Zone--------------------- Region---------------------Date---------Month----------Year-------------


Count on Tally

Count on Report

Match (write Yes or

No)


1

2

3

4

5

6

7

8

9

10

11

12

Total Yes

LQAS score


Sample Size


Less than 20% 20% 25% 30% 35% 40% 45% 55% 60% 65% 70% 75% 80% 85% 90% 95%

12 N/A 1 1 2 2 3 4 5 6 7 7 8 8 9 10 11


Lot Quality Assurance Sampling working Template IPD report

Hospital Name----------------------------------------------------- Woreda---------------------------- Zone--------------------- Region---------------------

Date------------------ Month--------------- Year---------------


Count on Tally

Count on Report

Match (write Yes or

No)


1

2

3

4

5

6

7

8

9

10

11

12

Total Yes

LQAS score


Sample Size


Less than 20% 20% 25% 30% 35% 40% 45% 55% 60% 65% 70% 75% 80% 85% 90% 95%

12 N/A 1 1 2 2 3 4 5 6 7 7 8 8 9 10 11


S/N Data Elemenets with Inconsistency Possible Causes for this Inconsistency Actions Taken Way Forward

1

2

3

4

5

6

7

8

9

10

11

12


INTERA DATA ELEMENT INCONSISTENCY CHECK SHEETMonth----------------Year---------------

PMT Meeting Minute BookDate:________________Time:________________

Participants:S/N Full Name Department Position Signature

1

2

3

4

5

6

7

8

9

10

Agenda:

Performance Monitoring Template

S.No Selected indicator Current Month Performance

Previous Month performance

Cumulative to Date Performance Target

Previous Year the Same Reporting Period

Performance

Investigation Need (Yes,No) Remark

1

2

3

4

5

6

7

8

9

10

11

12

Discussion on the Performance Finding


Prioritizing the Problems

Indicator Magnitude of the Problem*

Seriousness of the problem* Community Concern* Feasibility of Inter-

vention* Total Score


Action Plan

Indicators to be investigated Main reason(s) Possible Cause(s) Solutions/Action Points Responsible Person/Section Time


Data Quality and Performance monitoring logbook Health Institution Level

FMOH V1 2009

Instruction for Data Quality and Performance Monitoring logbookFederal Democratic Republic of Ethiopia Ministry of Health

Woreda level report timeliness and completeness monitoring form

S/ No Write serial number as 1, 2, 3

Health Facility Name Write name of health Facility report recived from

Facility ownershipWrite the ownership of the Facility

OPD report received date Write the date OPD report received

IPD report received date Write the date IPD report received

Monthly service report received date Write the date monthly Service report received

Quarterly service report received date Write the date quarterly Service report received

Yearly service report received date Write the date yearly Service report received

Intera data element inconsistency checksheet

S/No Write serial number as 1, 2, 3

Data elemenets with inconsistency Write the data elements with inconsistency from DHIS 2 data validation output

Possible causes for this inconsistency Write possible causes for this inconsistency after discussion with PMT or fi nding from assessment

actions taken Write actions taken as corrected or not corrected

Way forward Write the suggested points for future improvement

FMOH V1 2009

Health Insitution/Woreda level Report Timeliness and Completeness Monitoring form Region------------- Zone ------------- Woreda--------- Month------------- Year ------------- E.C

Note: Write not applicable (NA) if it is not expected to report or it has not the service such as IPD

S.N Health Facility Name Facility ownershipOPD report Received Date

IPD report Re-ceived Date

Monthly Service report Received Date

Quarterly Service report Received Date

Yearly Service report Received Date

Total expected reportTotal report received during the given periodTotal report received timely

Federal Democratic Republic of Ethiopia Ministry of Health

S.N Data elemenets with inconsistency Possible causes for this inconsistency Actions taken Way forward12345678910111213141516171819202122232425262728

FMOH V1 2009

Intera Data Inconsistency ChecksheetMonth--------- Year ------------- E.C



FMOH V1 2009

Routine Data Quality assessment working Template

Data element

Facility Name Verifi cation factor1 2 3 4 5 6 7 8 9 10 11 12 Cumulative

Reported Reported Reported Reported Reported Reported Reported Reported Reported Reported Reported Reported Reported Reported/CountedCounted Counted Counted Counted Counted Counted Counted Counted Counted Counted Counted Counted Counted

Woreda--------- Zone ------------- Region

Note: RDQA should be conducted quarterly at health center (for HPs) ,woreda, zone and region based on the guideline


PMT Meeting Minute Book

FMOH V1 2009

Date: Time:

Participants:

Agenda:

Performance Monitoring Template

S.N Selected indicator Current Month Performance

Previous month performance

Cummulative to date

PerformanceTarget

Previous year the same reporting

period performance

Investigation need

(Yes,No)Remark


PMT Meeting Minute Book

FMOH V1 2009

Discussion on the Performance � nding



PMT Meeting Minute BookPrioritizing the Problems

FMOH V1 2009

Indicator Magnitude of the problem*

Serious ness of the problem*

Community concern*

Feasibility of intervention* Total score

Indicators to be investigated Main reason(s)Possible cause(s)

Solutions/Action Points

Responsible Person/section Time

Action Plan



Malaria RegisterContent / Home


Health Center Malaria Screening and Investigation

Register

SN Datum Comments1 S.N Write serial number starting from 001 for the patient to document in the regsiter

2Examination Date (DD/MM/YY)

Write the date patient visitied the health facilitity, written as (EC) Day /Month / Year (DD/ MM/YY)

3 Full Name of Patients Write the patient’s first name and father name

4 MRN Write unique individual identifier used on medical information folder.

5

Age If the patient is less than 5 years of age, enter the patient’s age in months -MM For example, a 4-month-old child is entered as 04M. If the patient is 5 years of age or older, enter the patient’s age in years -YY. For example, a 6-year-old child is entered as 06


7Pregnancy status (P/NP/NA) Write P= for Pregenant Women, NP= Non-Pregenant Women and NA= Not Applicable

8Address (Keble, Got, HH No.)/Phone No

Write Patient Keble, Got and/or House Hold Number on the upper row and the patient, Phone Number in the lower row

9History of fever in the last 48 hrs (Y/N)

Write fever history in the last 48 hours, Write Y= Yes for patient with fever history and N= No Fever history

10 Temperature (0C) Write the body temperatures taken under the arm using digital thermometer in ˚C

11

Travel history (Qolama)(Y, N)/ Travel Place Location

Write history of travel to malarias area (Kolama area) in the last 30 days and stayed at least one night, Write Y= Yes has travel history, N= No travel history on the upper row and Write the name of traveled place in the lower row

12

Diagnostic method (Mic/RDT/ Clinical)/Result ( N/Pf/Pv/Mix)

Write the diagnosis method used for the patients with malaria, Write Mic=Microspic, RDT=Rapid Diagnosis Method or Clinical = Clinical diagnosed by physicians in the upper row, Write the result of diagnosis N=Negative, Pf=Plasmodium falciparum, Pv= Plasmodium vivax, Mix=Mixed in the lower row

13Treatment* (1,2,3,4,5,6 and 7)

Write the treatment medication given, 1=ACT, 2=ACT+SLDPQ, 3= CQ, 4=CQ+RCPQ, 5=Artesuna-te Injection, 6= Other and 7=Referred

14

A visitor case (Y/N)/ A vis-itor, Stayed for 21 days or more? (Y/N)

A passively detected case staying temporarily within HF catchment with his/her relatives during his/her illness or infection period but not permanent residence of the kebele Write Y=Yes, N=No / If the case is visitor and stayed for 21 days or more in the area, Write Y=Yes, N=No

15Eligible for Investigation (Y/N)

A passively detected case staying temporarily within HF catchment with or without defined address during his/her infection or illness period for less than 21 days, about 21 days or more than 21 days, Write Y=yes, N=No

16The index case notified for investigation (Y/N/NA)

If the identified index case communicated to health post for investigation, Write Y=Yes, N=No or NA=Not Applicable

17Date FTAT started (DD/MM/YY) /Date FTAT completed (DD/MM/YY)

Write the started date for reactive focal test and treat (FTAT) in the upper row and completed date in the lower row, written as (EC) Day /Month / Year (DD/ MM/YY)

18The index case investigated and classified (Y/N)

Write Y= Yes if the index case investigated and classified, N=No, if not investigated and not classified

19Number of HH members tested within 70 m radus from the index case

Write the number of people tested within 70 m radius from the index cases

20

Number secondary cases identified from the index case investigation/Number of imported secondary cases

Write the number of secondary cases identified from the index case investigation in the upper row and number of imported cases from the secondary cases in the lower row

21Foci investigation done round the index case (Y/N)

Write Y= Yes if the foci investigation done around index case, N=No if foci investigation not done

22 Remark Write any supporting information

Instruction How To Complete Malaria Screening and Investigation Registration on Health Center

S.NExamination

Date (DD/MM/YY)

Full Name of Patients MRN Age Sex (M/F)

Pregnancy status (P/NP/NA)

Address (Kebele,

Got,HH No.)History of

fever in the last 48 hrs (Y/N)

Temperature (0C)

Travel history (Qolama)

(Y, N)/

Diagnostic method

(Mic/RDT/ Clinical) Treatment*

(1,2,3,4,5,6 and 7)

A visitor case (Y/N)

Eligible for Investigation

(Y/N)

The index case

notified for investigation

(Y/N/NA)

Date FTAT started (DD/

MM/YY) The index

case investigated

and classified

(Y/N)

Number of HH

members tested

within 70 m radius from

the index case

Number secondary

cases identified from the index case investigation?

Foci investigation done round

the index case (Y/N)

Remark

Phone #) Travel Place Location

Result ( N/Pf/Pv/Mix)

A visitor, Stayed for 21 days or more? (Y/N)

Date FTAT completed (DD/MM/

YY)

Number of imported secondary

cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Health Center Malaria Screening and Investigation Registration

*Treatment Options: (Col. 13 ) 1=ACT, 2=ACT+SLDPQ, 3= CQ, 4=CQ+RCPQ, 5=Artesunate Injection, 6= Other and 7=Referred

MSD Registers & Tally sheetsContent / Home


Health Center /WorHo & HospitalAmbulance Service Register

Description of the patients’ information filled on main part of registerColumn Num-ber

Datum Description

(1) S/No Enter sequentially starting from 1 until the budget year end and start again from 1 at the first day of new budget year

(2) Date Write the date received the call as DD:MM:YY

(3) Time of call Write the time received the call as HH:MM

4 Full Name of Call Handler Write the name of the person who handled the call

5 Full Name of Caller Write the name of the person who made the call

6 Phone number of Caller Write the phone number of the caller

7 Name of patient Write the name of the patient who need ambulance service

8 Sex Write sex of patient as M for Male and F for Female

9 Age Write age of patient (if it is under 1 month enter in days, if it is under 5 year, enter in month and enter in year if it is above 5 year old)

10 Sub city/Zone Write the current sub city/zone of the patient

11 Woreda Write the current woreda of the patient

12 Kebele/Gote Write the current Kebele/Gote/Unique name of the neighborhood of the patient

13 Tel. Number Write telephone number of the patient

14 Reason for Ambulance RequestWrite the code of the reason for request as 1. Labor & Obstetric Emergency 2. Neonatal Emergency 3. RTA 4. Trauma (Specify)- Applies for Falling Down Accident, Fighting Accident, Occupational Accident,Animal Bite or Attack, others 5. Non-traumatic emergencies (Specify) 6. Burn 7. Poisoning

15 Ambulance Dispatched Write the response as Yes or No for all requests

16 Reason (if ambulance is not dis-patched)

Enter the codes given as reasons 1= Available ambulances dispatched 2= Inadequate or Missing medical equipment/materials/consumables 3. Professionals (HCW or Driver) not available 4. No Fuel 5. On Main-tenance 6. Administration 7. Not ready for service (not cleaned or disinfected)

17 Type of Ambulance Write the codes: 1. Unequipped basic ambulance, 2. Basic ambulances equipped based on the minimum basic ambu-lance requirement, 3. Standard advanced

18 Time of Call Directed to Ambulance Professional

Write the exact time at which the call handler informed the ambulance professionals of the case /ordered dispatch as HH:MM

19 Time of ambulance dispatch Write the exact time the ambulance physically dispatched

20Person accompanied the patient (1. EMT, 2.nurse or other health professional 3. Not accompanied

Write 1 if it is accompanied by EMT , write 2 if it is nurse or other health professional and write 3 if Not accompanied

21 Time of arrival at the patient’s location Write the time of ambulance arrival at Client/ patient’s location HH:MM which is filled by EMT

22 Condition of patient on arrival Write the response as 1. Alive 2. Dead 3. Patient not found

23 Time of ambulance arrived at HF Write the time of ambulance arrival at health facility as HH:MM

24 Critical Incident during transportCode (1,2,3,4,5)

Write the response using code as 1. Patient Deterioration (deterioration in vital signs or GCS) 2. Patient Arrest 3. Equipment failure/malfunction 4. Depletion of Consumables 5.External Factor (Ambulance breaks down, No Fuel, Roads are blocked crowded, Security/Safety Issues)

25 Name of receiving health facility Write the name of Health facility the ambulance takes the patient

26 Remark Write any thing regarding ambulance service or patient status, if any challenge faced during the service

Instruction for Ambulance Call & Dispatch Service Register

This register is kept at woreda health office

Information filled at front page of registerRegion Write region name where the facility is locatedZone/Sub city /Woreda Write Zone/Sub-City /Woreda name where the facility is located.Facility Name Write the name of the health facility where the service was providedRegister begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Write the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

S/No

Service Date

(DD/MM/YY)

Time of call

(HH:MM)Name of Call Handler Full name of caller

Phone number of

callerName of patient Sex

M/F AgeSub city/Zone

Woreda Kebele/Gote

Phone # of Patient

Reas

on fo

r Req

uest

Ambu

lance

Disp

atche

d (Y/

N)

Reason (if ambulance

is not dispatched (1,2, 3,4,5,

6, 7)

Type

of A

mbula

nce D

ispatc

hed (

write

code

)Tim

e of C

all D

irecte

d to A

mbula

nce

Profe

ssion

al

Tim

e of a

mbula

nce d

ispatc

h

Profe

ssion

al ac

comp

anyin

g the

patie

nt in

ambu

lance

(1.E

MT, 2

.Nur

se or

othe

r pr

ofess

ional,

3.no

t acc

ompa

nied)

Time of arrival at patient’s location

Condition of patient on Arrival (1. Alive, 2. Dead,

3.not found)

Time of ambulance arrival at

HF

Critical Incident during

Transport (Write code)

Name of Receiving

Health Facility

Remark

(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) 26

Ambulance Service Register

Count total calls

Reason for Request col (14)1. Labor & Obstetric Emergency2. Neonatal Emergency3. RTA4. Trauma (Specify)- 5. Non-traumatic emergencies (Specify)6. Burn7. Poisioning

Count the cases for which ambulance was dispatched

Reason (if ambulance is not dispatched) col (16)1= Available ambulances dispatched2= Inadequate or missing medical equipment/consumables3. Professionals (HCW or Driver) not available4. No Fuel5. On Maintenance6. Administration7. Not ready for service (not cleaned or disinfected)

Count

EMT

Nurse or other heath professional

Not accompanied

Type of Ambulance Dispatched col (17)1. Unequipped basic ambulance, 2. Basic ambulances equipped based on mini-mum requirements, 3. Standard advanced Critical Incident during Transport col (24) 1.Deteriorate, 2. Arrest, 3. Equipment malfunction 4. Depletion of consumable 5. External factor


Special Center/ Hospital Assistive Technology Service Register

Description of the patients’ information filled on main part of registerColumn Number

Datum Description

1 S.NWrite Sequential serial number in registration book; to be entered on patient’s summary sheet to link integrated medical records folder with register

2 DateWrite the date of attendance at card room, written as (EC) Day / Month / Year (DD/MM/YY)

3 MRNWrite unique individual Medical Record Number used on integrated medical records folder

4 Name Write full name of the patient/ Client

5 AgeWrite age in years. If patient/Client is under 1 year, enter age in months, followed by M. If patient is under 1 month, enter age in days, followed by D.

6 Sex Write M for Male or F for Female

7 Woreda/ Kebele Write the Woreda/ Kebele of the Client

8 Phone number Write the phone number of Client

9 Disability status Ask the disability status of the patient and write as 1= Physical impairment, 2 = hearing Impairments 3= mobility impairment, 4. Psychical impairment 5. Visual impairment 6. Other

10 Service Delivery Write the service given to the client

11 Payment type Write the payment type as 1 = CBHI, 2 = Credit, 3 = Cash, 4= Donation

12 Remark Write any comment or appointment date accordingly

Instruction for AT Service RegisterAssistive Technology Service Register Clinic

Information filled at front page of registerRegion Write region name where the facility is located



Register begin dateWrite the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register end dateWrite the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

S.NService Date (DD/MM/YY)

MRN Name Age SexAdress

Disability type*Service

DeliveredPayment type Remark

Worda/Kebele Phone number

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

*Disability type Count

1. Physical Impairment

2. Hearing Impairment

3. Mobility Impairments

4. Psychical Impairment

5. Visual Impairment

6. Others

Assistive Technology Service Register


Health Center /Clinic/ Hospital Central Register

Description of the patients’ information filled on main part of register

Column Number Datum Description

(1) S/No Sequential serial number in registration book; to be entered on patient’s summary sheet to link integrated medical records folder with register

(2) Date Date of attendance at card room, written as (EC) Day / Month / Year (DD/MM/YY)

(3) MRN Unique individual identifier used on integrated medical records folder

(4) Name Write full name of patient

(5) Age Enter age in years. If patient is under 1 year, enter age in months, followed by M.If patient is under 1 month, enter age in days, followed by D.

(6) Sex M=Male; F=Female

(7) Disability status

Enter by asking the patient for disability status as 1= Vision loss, 2 = hearing loss 3= mobility impairment, 4. No disability , If other specify__________

(8) Payment type

Enter the payment type as 1 = CBHI, 2 = Credit, 3 = Cash, 4 = Exempted 5= fee waiver

Instruction for Central Register

This register is kept at Medical Record Unit


Region Write name of the region which health facility is located

Zone Write name of the zone which health facility is located

Woreda Write name of the woreda which health facility is located

Facility Name Write name of health facility which should be consistent with the name at License

Register begin date Enter the date of first entry in the register as DD/MM/YYYY

Register end date Enter the date of last entry in the register as DD/MM/YYYY

S.N. Date MRN Name Age Sex

Disability status: 1= Vision loss 2= Hearing loss 3= Mobility impairment 4= No disablity If other specify____

Payment type 1 = CBHI 2 = Credit 3 = Cash 4 = Exempted 5 = Fee waiver

(1) (2) (3) (4) (5) (6) (7) (8)

Count Total

Number of CBHI

Number of credit

Number of Cash payer

Number of exempted

Number of fee waiver

Central Register


Health Center /Clinic/ Hospital Emergency Unit/ Department

Register



(1) S/No Write sequentially starting from 1 until the budget year end and start again from 1 at the first day of new budget year(2) Date Write date of visit for emergency care(3) MRN Write Medical Record number from individual folder(4) Patient Name Write patient name from his/her individual folder

(5) Age Write age of patient (if it is under 1 month enter in days, followed by “0” if it is under 5 year, enter in month followed by “M” and enter in year if it is above 5 year old)

(6) Sex (M) (F) Write sex of patient as M for male and F for Female7 Tme of Arrival at HF HH:MM Write the hour and minute of arrival at Health Facility8 Time seen by traige officer (HH:MM) Write the hour and minute the patient seen by triage officer

9 Mode of Arrival (Ambulance, Police car,Other specify ) Write the code of Mode of Arrival as 1. Ambulance 2. Walk in 3. Police Car 4. Motored Vehicles 5.Other means of transport

10 Patient Handover from AmbulanceWrite the response as 1. No handover (if patient was not handovered due to any reason) 2. With form (if a standard pre-hospital form is used to handover the patient) 3. Withour form (if a standard pre-hospital form is not used to handover the patient)

11 Referral Source (Self, HC, Hospital,or Other) Write referral source (name and type of health facility) from the choice as (Self, HC, Primary Hospital, General Hospital, Specialized/Teritiary Hospital, Speciality Center, Private Clinic, Private Hospital)

12 Triage category* Write the code from the description on the foot note: 1 = red, 2 = orange, 3 = yellow, 4 = green, 5 = black

13 Diagnosis at arrival (ESV_ICD11) Write the diagnosis (name and code) based on Ethiopia Simplified Version International Classification of Disease (ESV_ICD11) as it appears on the hand book Table on computer (do not abbreviation)

14 New Tick (√) if visit is for a new episode of illness.(15) Repeat Tick(√) if visit is follow-up for a previous episode of illness.

16 Road Traffic Accident

Write the code for those patients who have RTA as: 1. Pedestrian ( person who have RTA by any type of vehicle . This doesn’t include Vehicle occupants ) 2.Motorcyclist(person who have RTA in vehicle with 3 wheels or less ) 3.Vehicle occupant(person who have RTA in vehicles with 4 and above wheels)

17 Immediate action After Triage Write the code from the description on the foot note:1 = Resuscitation, 2 = procedure/OR , 3 = Examination room/area, 4 = Waiting area

HIV assessment

(18) HIV test offered Tick (√) if patient is offered HIV test

19 HIV test performed Tick (√) if patient is tested

20 Targeted population category

Write the code target population category listed below the register.An individual needs to be assigned only in one category that best describe him/her. A. Female Commercial Sex workers B. Long distance drivers C. Mobile/Daily Laborers D. Prisoners

21 HIV test result (P/ N) Write P in red pen if test result is Positive; N in normal color of pen if test result is negative;

(22) Diagnosis at Disposition from Emergency Department or Unit (ESV_ICD11)

Write the diagnosis (name and code) based on Ethiopia Simplified Version International Classification of Disease (ESV_ICD11) as it appears on the hand book Table on computer (do not abbreviation)

23 Date and time of decision of disposition Enter the date and time of Clinician’s decision of the disposition as DD:MM:YY for date and HH:MM:SS for time- -

24 Date & Time of Actual Disposition Enter the date and time of actual disposition (when the patient walks out of the ER for admission, to home or is referred) as DD:MM:YY for date and HH:MM:SS for time- -

25 length of stay in hour Calculate and enter length of stay as >=24 and < 24Patient out come

26 Reffered Tick (√) if patient is referred or transferred out

27 Stabilizeded and discharge Tick (√) if the patient is stabilized and discharged

28 Admitted Tick (√) if the patient is admitted to inpatient department

29 Died Tick(√) if the patient is died

30 Death Notification Write Yes or No for deaths notified using appropriate death notification form and do not write Cause of death as Cardio pulmonary arrest or Respiratory Failure

31 Remark Write any thing regarding the patient or other

Instruction for Emergency department/unit register This register is kept at emergency department/unit triage area

Information filled at front page of registerRegion Write region name where the facility is locatedZone/Sub city /Woreda Write Zone/Sub-City /Woreda name where the facility is located.Facility Name Write the name of the health facility where the service was providedRegister begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register end date Write the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

E. OVC F. Children of PLHIV G. Partners of PLHIV H. Other MARPS I. General population

S.N

Service Date

(DD/MM/YY)

MRN Patient Name Age Sex M/F

Time ofArrival at HF

(HH:MM)

Time seen by traige officer

(HH:MM)

Mode

of A

rriva

l* wr

ite co

dePa

tient

Hand

over

from

Amb

ulanc

e write

co

de

Referral Source (Name & type of facility_Self, HC, Primary Hosp, Gen

Hosp, Specialized/

Teritiary Hosp, Speciality

Center, Private Clinic, Private

Hosp)

Triag

e cate

gory*

* write

code

Diagnosis on Arrival [ESV_ICD11]

New(

√)Re

peat(

√)Ro

ad Tr

affic

Acc

iden

t: 1.

Pede

strian

2.Mo

torcy

clist

3.Veh

icle

occu

pant

Imme

diate

Actio

n Afte

r Tria

ge **

HIV Assessment

Diagnosis at Disposition from (ESV_ICD11)

Date & Time of Decision

for Disposition

Date

and

tim

e of A

ctua

l Disp

ositi

onLe

ngth

of s

tay i

n ho

ur

Outcome at Disposition

Remark

HIV

test o

ffere

d(√)

HIV

test p

erfor

med(

√)Ta

rgete

d pop

ulatio

n cate

gory

HIV

test r

esult

(P, N

)

Reffe

red

(√)

Stab

ilized

and

disc

harg

e (√)

Adm

itted

(√)

Died

(√)

Deat

h No

tifica

tion

give

n

Name Code Name Code(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) (26) (27) (28) (29) (30) 31

Emergency Unit/ Department Register

*Mode of Arrival col (9)1. Ambulance2. Walk in 3. Police Car4 . Motored Vehicles5. Other means of transport

Count total emergency

attendances

**Triage category col (12) 1 = Red 2 = Orange 3 = Yellow 4 = Green 5= Black

Patient Handing over col (10) 1. Not handed over 2. Handed over with form 3. Handed without form

** Action (17) 1 = Resuscitation 2 = Procedure/OR 3 = Examination room/area 4 = Waiting area"

Targeted population category (20)A. Female Commercial Sex workersB. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPSI. General population

Count stayed >=24 hours

Count death with 24hours

Count death >=24

hours

Count death

age <=15 male

Count death

age <=15 female

Count death

age >15 Female

Count death

age >15 male

Counted notified deaths

Count with Ambulance

Pre-Health Facilities

B/n Health Facilities

Count Referral Source

Self Health Facility


Hospital Intensive Care Unit Register

Description of the patients’ information filled on main part of registerColumn Number Datum Description

1 S/No Enter sequentially starting from 1 until the budget year end and start again from 1 at the first day of new budget year

2 MRN Enter unique identifier Medical Record Number of the Patients

3 Patient name Write patient name from his/her individual folder

4 Age Write age of patient (if it is under 1 month enter in days, followed by “0” if it is under 5 year, enter in month followed by “M” and enter in year if it is above 5 year old)

5 Sex Write sex of patient as M for male and F for Female6 Date admitted Enter date patient admitted at ICU

7 Diagnosis at admission (ESV_ICD11)


HIV assessment

8 HIV test offered Tick if patient is offered HIV test

9 HIV test performed Tick if patient is tested

10 Targeted population category

Write the code from target population category listed at the bottom of the register . Individual needs to be as-signed only in one category that best describe him/her. A. Female Commercial Sex workers B. Long distance drivers C. Mobile/Daily Laborers D. Prisoners

11 HIV test result (P,N) Write P in red pen if test result is Positive; N in normal color of pen if test result is negative;

Invasive mechanical ventilation12 Yes/No Write yes if patient received mechanical ventilation if not write No13 Days in number Enter number of days patient on mechanical ventilation

Ventilator Associated Pneumonia (VAP)

14 Yes/No Write “yes” if the patient developed pneumonia after mechanical ventilation Write “No” if the patient did not developed pneumonia after mechanical ventilation

15 Yes/No Write "yes" if the patient is assessed for malnutrition, otherwise write "No"

16 Yes/No Write "yes" if the patient is given nutritional support, otherwise write "No" 17 1. Enteral 2. Parenteral Write the feeding tpye either "Enteral" or "Parenteral" 18 Date discharged Enter when patient get discharged date irrespective of the outcome

19 Diagnosis at discharge(ESV_ICD11)


20 Length of stay in ICU in days Write the length of stay in the ICU in days (calculate the difference between the date of ICU discharge and the date of ICU admission) NB: If the patient discharged on the admission day, then the length of stay will be zero

21 Patient outcome at discharge Write the code from the description on the foot note:1 = discharged alive 2 =Admitted to inpatient Department 3 = died 4. referred or transfered out 5= other

Death in the ICU

22 Within 24 hours/After 24 hours Write “1” if the death in the ICU occurred within 24 hours Write “2” if the death in the ICU occurred after 24 hours

Death Notification Given

23 Yes/No Write “Yes” if notification is given for the death occurred in the ICU Write “No” if notification is not given for the death occurred in the ICU

ICU Readmission

24 Yes/No Write “Yes” if the patient is readmitted to the ICU Write “No” if the patient is not readmitted to the ICU

25 1. Within 48 hrs 2. After 48 hrs

Write “1” if the patient is readmitted within 48 hours Write “2” if the patient is readmitted after 48 hours

26 Remark Write any thing regarding the patient or other

Instruction for Intensive Care Unit register


This register is kept at ICUInformation filled at front page of register






S.N MRN Patient Name Age SexM/F

Date admitted

DD/MM/YY

Diagnosis at admission (ESV_ICD11)

HIV AssessmentInvasive

mechanical ventilation

VAP Deve-loped

Nutrition Services Patient information at dischargeDeath in the ICU

Death Notifi-cation Given

ICU Readmission

Remark

HIV

Tes

t Offe

red

(√)

HIV

Tes

t per

form

ed (√

)

Targ

eted

pop

ulat

ion

cate

go-

ry (c

ode)

HIV

test

resu

lt (P

,N)

Y=Y

es/N

=No

Day

s in

num

ber

Y=Y

es/N

=No

Nut

ritio

nal A

sses

smen

t co

nduc

ted

(Yes

/No)

Nut

ritio

nal S

uppo

rt gi

ven

(Yes

/No)

Feed

ing

Type

(1. E

nter

al 2

. P

aren

tera

l ) Date dis-charged DD/MM/

YY

Diagnosis at discharge (ESV_ICD11)

Leng

th o

f sta

y in

ICU

(in

days

)

Pat

ient

out

com

e at

dis

-ch

arge

** (1

,2,3

,4, 5

)

1. W

ithin

24

hrs

2. A

fter 2

4 hr

s

Y=Y

es/N

=No

Y=Y

es/N

=No

1. W

ithin

48

hrs

2. A

fter 4

8 hr

s

Name Code Name Code

(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) (26)

Intensive Care Unit Register

Targeted population category Col. 10 A. Female Commercial Sex workersB. Long distance driversC. Mobile/Daily LaborersD. PrisonersI. General population

Patient outcome at discharge code* Col.211 = Discharged 2 = Admitted to inpatient Department3 = Died 4 = Referred 5 = Other

Count

Patient on Mechanical ventilation

Death with MV

Death without MV

Death within 24 hrs

Death After 24 hrs

Count

VAP Developed

Length of stay in days in ICU

Total Discharge


E. OVC F. Children of PLHIVG. Partners of PLHIVH. Other MARPS


Health Center /Clinic/ Hospital Admission/ Discharge Register


Identification(1) S.N Write sequential serial number in registration book; to be entered on patient’s summary sheet to link integrated medical records folder with register(2) MRN Write unique individual identifier used on integrated medical records folder(3) Age Write age in years. If patient is under 1 year, enter age in months, followed by M.If patient is under 1 month, enter age in days, followed by D.(4) Sex Write M for Male or F for Female(5) Woreda/Sub city Write woreda/Sub city name where patient resides

Admission

(6) Date of Admission (DD/MM/YY) Write the date of admission in IPD, written as (EC) Day / Month / Year (DD/MM/YY)

(7) ESV_ICD11 Diagnosis Write the diagnosis (name and code) based on Ethiopia Simplified Version International Classification of Disease (ESV_ICD11) as it appears on the hand book Table on computer (do not abbreviation)

(8) Road Traffic Accident

Write the code for Road Traffic Accident (RTA) as: 1. Pedestrian ( person who have RTA by any type of vehicle . This doesn’t include Vehicle occupants ) 2.Motorcyclist (person who have RTA in vehicle with 3 wheels or less ) 3.Vehicle occupant (person who have RTA in vehicles with 4 and above wheels)

Provider initiated testing and counseling (PITC)(9) HIV Test Offered Tick (√) if HIV test offered under provider initiated HIV counseling and testing guidelines

(10) HIV Test performed Tick (√) if client tested for HIV/AIDS.

(11) Targeted population category

Write the target population category code listed at the bottom of the register. An individual needs to be assigned only in one category that best de-scribe him/her. A. Female Commercial Sex workers B. Long distance drivers C. Mobile/Daily Laborers D. Prisoners

(12) HIV Test result (P/N) Write P in red pen if test result is Positive; N in normal color of pen if test result is negative; Travel History to Malarious Area

(13) Travel History to malarious area Tick (√) if a patient has travel history to malarious areas

TB screening(14) Screened for TB Tick (√) if a patient is screened for TB

(15) TB screening result Write “N” if a patient is screened negative or “P” if a patient is screened positive

(16) Type of diagnostic eval-uation

Write code for the type of diagnostice evaluation as: 1. Sputum smear microscopy 2. Sputum GeneXpert 3. X-ray/other imaging

(17) Result of TB screening write code for TB screening result of the diagnostic evaluation as: TB, No TB, Not decided (ND)Discharge

(18) Date of Discharge (DD/MM/YY) Write the date of discharge from IPD, written as (EC) Day / Month / Year (DD/MM/YY)

(19) Length of stay (days) Write the number of days in which the patient Stayed in hospital (Date of discharge minus date of admission)

(20) Condition at discharge Write ‘A’for improved, ‘B’ for same, ‘C’ for deteriorated, ‘D’ for left against medical advice (LAMA), ‘E’ for died ‘F’ for referred to higher facility, and ‘G’ for absconded.


Death in the IPD

(22) Within 24 hours/After 24 hours

Write “1” if the death in the IPD occurred within 24 hours Write “2” if the death in the IPD occurred after 24 hours


(23) Yes/No Write “Yes” if notification is given for the death occurred in the IPD Write “No” if notification is not given for the death occurred in the IPD

Finance(24) Amount charged (birr) Write the amount of money in Birr charged by service provider during the admission(25) Amount paid (birr or free) Write the payment presented by service recipient for the service throughout his/her stay(26) Voucher No Write the voucher number on receipt for payment(27) Remark Any comment suggestion, follow up that the provider would like to document.

INSTRUCTIONS FOR INPATIENT ADMISSION/DISCHARGE REGISTER

Register kept in IPD room (HC/Hospital-AdmDisReg). Completed by nurse at time of admission and discharge.Location information to be completed at front of register:







4. Histopathologic test 5. other (specify) 6. Not done

Identification Admission

Road Trafic

Accident: 1. Pedes-

trian 2.Motorcy-

clist 3.Vehiclle occupant

Provider initiated testing & counsel-

ing (PITC)

Trav

el Hi

story

to ma

lariou

s are

a (√)

TB screening DischargeDeath in the IPD

Death Notification

GivenFinance

RemarkS/No MRN Age Sex

(M/F)Woreda/Sub city

Date of Admis-

sion (DD/MM/

YY)

ESV_ICD11 Diagnosis

HIV

Test

Offer

ed (√

)

HIV

Test

perfo

rmed

(√)

Targ

eted p

opula

tion c

atego

ry (co

de)

HIV

Test

resu

lt (P

or N

)

Scre

ened

for T

B (√

)

TB sc

reen

ing re

sult (

P/N)

Type

of di

agno

stic e

valua

tion (

write

co

de)

Resu

lt of T

B sc

reen

ing(co

de: T

B, N

o TB

, Not

decid

ed (N

D))

Date of Discharge (DD/MM/

YY)

Length of stay (days)

Condition at discharge

code *

ESV_ICD11 Diagnosis

1. W

ithin

24 hr

s 2.

After

24 hr

s

Y=Ye

s/N=N

o

Amount charged

(birr)

Amount paid (birr or free)

Voucher No

Name Code Name Code

(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) (26) (27)

Admission/ Discharge RegisterName of Ward:_______________________________

Count admissionsCountPedestrianMotorcyclistVehicle occupant

CountDeaths Within 24 hrsDeaths After 24 hrsDeath Notification Given

Count SumDischarges Days

Targeted population category (Col.11)A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersI. General population

E. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPS

Condition at discharge (Col. 20)A. Improved B. Same C. Deteriorated D. Left against medical

E. Died F. Referred to higher G. Absconded


Hospital Liaison Referral-in/out Register




Register begin dateWrite the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)



1 S/NoEnter sequentially starting from 1 until the budget year end and start again from 1 at the first day of new budget year

2 MRN Enter Medical Record Number from individual folder

3 Date Write the date the patient is referred in as DD/MM/YY

4 Name of the patient Write the name of the patient

5 AgeWrite age of patient (if it is under 1 month enter in days, followed by “0“ if it is under 5 year, enter in month followed by “M“ and enter in year if it is above 5 year old)

6 Sex write sex of patient as M for male and F for Female

7 Address: Region Write the current region of the patient

8 Address: Sub City/zone Write the current sub city/zone of the patient

9 Address: Woreda/kebele Write the current woreda of the patient

10 Referral in (✓) Tick if the case is referral in

11 Referral out (✓) Tick if the case is referral out

12Name of referring or receiving facility

Write the name of the health facility that referred the patient or the facility to which the patient is referred to from the referral paper

13 Type of case Type of case can be emergecy or cold. Write 1 if the case is emergecny and 2 if the case is cold in the column space.

14Referral in or out Diagnosis

Write the diagnosis of the patient (either referred in or out) that is written on the referral paper

15Department linked to or that referred-out the patient

Write the name of the department that either referred out or to which the patient was linked

16Reason for referral in or out

Choose the reason for referral in or out from the lists provided at the bottom of the coumn and write the corresponding number. 1= Better Diagnosis & Management, 2=Lack of Bed, 3=Self-referral (eg. financial reasons,etc) 4=Administrative (eg. Power outage, equipment malfunction) 5= Others (eg. medico-legal)

17 Referral with ambulance If the patient was referred in with ambulance write “Y for Yes. If not, write ‘N” for No.

18Referral in or out with Communication

If the patient was referred in with communication write “Y” for Yes. If the patient was referred without communication write ‘N” for No.

19 Payment Type Write the type of payment 1 = Cash 2 = CBHI 3 = Credit 4 =Exempted 5 = Fee Waiver

20Feedback received or sent

Write “Y’ for Yes if feedback was received from or sent to the facility the patient was referred. Write “N” for No if feedback was not received or sent to the facility at the end of the monthly reporting period.

21 2. Cash payer Write any thing regarding the patient in the remark section

Instruction for Liaison Referral in/out registerThis register is to be kept at the Liaison Office

Identification Referral service

S/N

Service Date (DD/

MM/YY)

MRN Name of the patient Age SexAddress Type of

referral Name of Re-

ferring Facility or facility to which client referred to

Type of Case**

Referral in or out Diagnosis

Department linked to or that

referred-out the patient

Reason for Referral in or

out*

Emergency referral with Ambulance

(Y/N)

Referral in or out with

Communication (Y/N)

Payment Type.

Feedback received or Sent (Y/N)

Remark Region Subcity/

Zone Woreda/Kebele Referral in (√)

Referral out (√)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21)

Count Count Count referrals with ambulanceTotal referral-in

Emergency referral-in

Referrals with ambulance

Liaison Referral-in/out Register

*Reasoin for referral (column 16) 1 = Better diagnosis and care 2 = Lack of Bed 3 = Self referral 4 =Administrative reason 5 = Expert advice6 = Others

**Type of case (column 13) 1 = Emergency2 = Cold case

Payment Type (column 19) 1 = Cash 2 = CBHI 3 = Credit4 =Exempted5 = Fee Waiver


Health Center /Clinic/ Hospital Out Patient Department Register

Instruction for Outpatient Department OPD Abstract Register

This register is kept at OPD


Region Write name of the region which health facility is located

Zone Write name of the zone which health facility is located

Woreda Write name of the woreda which health facility is located

Facility Name Write name of health facility which should be consistent with the name at Liscence

Register begin date Enter the date of first entry in the register as DD/MM/YYYY

Register end date Enter the date of last entry in the register as DD/MM/YYYY



Identification

(1) S/NoSequential serial number in registration book; to be entered on patient’s summary sheet to link integrated medical records folder with the register

(2)Service Date (DD/MM/YY)

Date of attendance at OPD, written as (EC) Day / Month / Year (DD/MM/YY)

(3) MRN Unique individual identifier used on integrated medical records folder

(4) AgeEnter age in years. If patient is under 1 year, enter age in months, followed by M.If patient is under 1 month, enter age in days, followed by D.

(5) Sex (M/F) M=Male; F=Female

(6) Address Write Woreda/ Kebele of patient

Diagnosis


(8) New (√) Tick if visit is for a new episode of illness.

(9) Repeat (√) Tick if visit is follow-up for a previous episode of illness.


Write the code for those patients who have RTA as: 1. Pedestrian ( person who have RTA by any type of vehicle . This doesn’t include Vehicle occupants ) 2.Motorcyclist(person who have RTA in vehicle with 3 wheels or less ) 3.Vehicle occupant(person who have RTA in vehicles with 4 and above wheels)

Provider Initiated HIV Counseling and Testing (PIHCT) (11) HIV Test Offered (√) Tick if HIV test offered under provider initiated HIV counseling and testing guidelines

(12) HIV Test performed (√) Tick if client tested for HIV/AIDS.

(13) Targeted population category

Fill column 13 selecting from the list of target population category listed, an individual needs to be assigned only in one category that best describe him/her. A. Female Commercial Sex workers B. Long distance drivers C. Mobile/Daily Laborers H. Other MARPS I. General population

(14) HIV Test result (P or N) Enter P in red pen if test is positive; N in normal color of pen if test is negative.

(15) Travel histroy to malarious area (√)Tick if a confirmed case of malaria had travel history to malarious areas, This should not ticked for un-confimred cases.

TB screening & Investigation(16) Screened for TB (√) Tick if a patient is screened for TB

(17) TB screening result (P/N) Write “N” if a patient is screen negative or “P” it a patient is screen positive

(18)Type of diagnostic evaluation (write code)

Write type of diagnostice evaluation 1. Sputum smear microscopy 2. Sputum GeneXpert 3. X-ray/other imaging

(19)Result of TB screening(code: TB, No TB, Not decided (ND))

Write code fpr TB screening result of the diagnostic evaluation (code: TB, No TB, Not decided (ND))

(20) Referred to*Enter 1 if patient referred to hospital; 2 if referred to Health Center; 3 if referred to Health Post; 4 if referred to MCH care; 5 if referred to ART; 6 if referred to SOPD (Surgical Outpatient Department); 7 if referred to Ob/Gyn; 8 if referred to TB Clinic; 9 if referred to another service / health institution.

(21) Died Tick patient is died at OPD level (Dead on arrival (DOA) or while on tretament at the OPD level before admission.

(22) Death notification Tick if death notification form was filled and given to family members or the police

(23) Remark Any comment, suggestion follow-up etc, that the provider would like to document

D. Prisoners E. OVC F. Children of PLHIV G. Partners of PLHIV

4. Histopathologic test 5. Other (specify) 6. Not done

Identification Diagnosis

Road Traffic Accident:

1. Pedestrian 2.Motorcyclist

3.Vehiclle occupant

Provider Initiated HIV Coun-seling & Testing (PIHCT)

Trav

el his

troy t

o mala

rious

area

(√) TB screening &

Investigation

Referred to** Di

ed (√

)

Death

notifi

ed (√

)

RemarkS/No Service Date

(DD/MM/YY) MRN Age Sex (M/F)

Address (Woreda/ Kebele )

"ESV-ICD 11 (if patient admitted, do not write diagnosis, write admitted)" New

(√)Repeat

(√)

HIV

Test

Offer

ed (√

)

HIV

Test

perfo

rmed

(√)

Targ

eted p

opula

tion c

atego

ry (co

de)

HIV

Test

resu

lt

(P or

N)

Scre

ened

for T

B (√

)

TB sc

reen

ing re

sult

(P/N

)Ty

pe of

diag

nosti

c eva

luatio

n (w

rite co

de)

Resu

lt of T

B sc

reen

ing(co

de:

TB, N

o TB,

Not

decid

ed (N

D))

Name Code

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23)

Count Count those with travel history

Count deathPedestrian

Motorcyclist

Vehicle occupant

Out Patient Department (OPD) Register

Targeted population category (Col. 13)A. Female Commercial Sex workers E. OVC B. Long distance drivers F. Children of PLHIVC. Mobile/Daily Laborers G. Partners of PLHIVD. Prisoners H. Other MARPSI. General population

** Referral codes for (Col. 20) 1 = Hospital 5 = ART 2 = Health Center 6 = SOPD 3 = Health Post 7 = ObGyn 4 = MCH 8 = TB Clinic 9 = if referred to another service / health institution

Type of diagnostice evaluation (Col. 18)1. Sputum smear microscopy 2. Sputum GeneXpert 3. X-ray/other imaging 4. Histopathologic test5. Other (specify)6. Not done


Health Center/Clinic/Hospital Operation Register

SN Datum Comment

1 S.N Write Sequential serial number in registration book; on client’s registration book for later identification in register

2 MRN Write Unique individual identifier used on medical information folder, for HC & Hospital

3 Sex Write M for Male or F for Female

4 Age

Write Age of the patient. If the patient is less than 5 years of age, enter the Client’s age in months -M For example, a 4-month-old child is entered as 4M or If the patient is 5 years of age or older, enter the Client’s age in years -YY. For example, a 6-year-old child is entered as 06.

5 Date of visit for operation Write date of operation service provision, DD/MM/YY

6 Ward Write the ward where the patient was admitted: medical, surgical, pediatric etc

7 Pre-operative diagnose Write the diagnose before operation (during admission/preoperative care)

Operation Procedure

8 Operation performed Write the reason for the current operation; medical reason etc

9 OR Type: Elective (L) or Emer-gency (E) (write L or E) Write L if the Operation procedure type is Elective and write E if it is Emergency

10 Post operative diagnose Write post operative diagnose when it is different from preoperative Dx, and Write ‘same’ when the Dx is similar with preoperative Dx

11 Type of anesthesia: General Tick (√) if the provided anesthesia was General

12 Type of anesthesia: Regional Tick (√) if the provided anesthesia was Regional

Operation procedure Duration

Starting Time Write the time when the procedure is started in hour and Minute (HH:MM)

End Time Write the time when the procedure is completed/end in hour and Minute (HH:MM)

Operation/Scrub Team

13 Surgeon Write full name of surgeon etc

14 1st Assistant Write full name of 1st Assistant

15 2nd Assistant Write full name of 2nd Assistant

16 Anesthetist Write full name of anesthetist

17 Scrub nurse Write full name of scrub nurse

18 Runner Write full name of Runner

Peri-Operation out come: Patient/client

19 Stable Tick (√) if the condition of the patient/client is stable

20 Critical Tick (√) if the condition of the patient/client is critical

21 Died Tick (√) if the condition of the patient/client is died Peri-operative death in OR: Death occurred in operation theatre before transfered to surgi-cal ward

Transfer to

22 1. ICU 2. Ward

Write “1” if the patient is transferred to ICU Write “2” if the patient is transferred to Ward

23 Remark Any comment, suggestion etc the provider would like to document

INSTRUCTIONS FOR OPERATION (OR) REGISTER

The operation register is completed from patient card by service provider.Location information to be completed at front of register:

Region Write region name where the facility is locatedZone/Sub city /Woreda Write Zone/Sub-City /Woreda name where the facility is located.Facility Name Write the name of the health facility where the service was providedRegister begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Write the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

Personal Information

Pre-Operative Diagnosis

Operation ProcedureType of

Anesthe-sia

Operation procedure duration

Operation/Scrub Team Peri-Operation Outcome Transfer to

Remark

Name of

S.N MRN Sex (F/M) Age Date (DD/

MM/YY) Ward Operation Performed

OR Type: Elective (L) or

Emergency (E) procedure (write L or E)

Post Operative Dx (Write “SAME”

if Similar Dx to preoperative Dx) G

eneral(√)

Regional(√)

Star

ting

Tim

e (H

H:M

M)

End

Tim

e (H

H:M

M)

Surg

eon

1st A

ssis

tant

2nd

Ass

ista

nt

Ane

sthe

tist

Scru

b nu

rse

Run

ner

Stable(√)

Critical(√)

Died(√)

1. IC

U

2. W

ard

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23)

Count Operation Performed

Count

Elective Surgery Count

Emergency Surgery Died

HEALTH CENTER/CLINIC/HOSPITAL OPERATION REGISTER


Hospital Surgery Register


Identification

(1) S.N Write sequential serial number in registration book; to be entered on patient’s summary sheet to link integrated medical records folder with register

(2) MRN Write unique individual identifier used on integrated medical records folder

(3) Age Write age in years. If patient is under 1 year, enter age in months, followed by M.If patient is under 1 month, enter age in days, followed by D.

(4) Sex Write M for Male or F for Female

(5) Woreda/Sub city Write woreda/Sub city name where patient resides

Admission

(6) Date Added to Waiting List (DD/MM/YY) Write the date when the patient is added to the waiting list Day / Month / Year (DD/MM/YY)

(7) Date of Admission (DD/MM/YY) Write the date of admission to surgical ward, written as (EC) Day / Month / Year (DD/MM/YY)

(8) Delay for elective surgical admission (in days)

Write the delay in days (the delay is the difference between the day the patient added to the waiting list and the date of admission to surgical ward)

(9) Pre-Operative Length of Stay (in days)

Write the length of stay in surgical ward in days (calculate the difference between the date of Operation and the date of admission)

(10) Pre-Operative Diagnosis Write the diagnose at admission/preoperative care

(11) OR Type: Elective (L) or Emergency (E) (write L or E) Write L if the Operation procedure type is Elective and write E if it is Emergency

(12)Post Operative Dx (Write “SAME” if Similar Dx to pre-operative Dx)

Write post operative diagnose when it is different from preoperative Dx, and Write ‘same’ when the Dx is similar with preoperative Dx


Write the code for Road Traffic Accident (RTA) as: 1. Pedestrian ( person who have RTA by any type of vehicle . This doesn’t include Vehicle occupants ) 2.Motorcyclist (person who have RTA in vehicle with 3 wheels or less ) 3.Vehicle occupant (person who have RTA in vehicles with 4 and above wheels)

INSTRUCTIONS FOR SURGICAL WARD REGISTER

Register kept in surgical ward (HC/Hospital-AdmDisReg). Completed by nurse at time of admission and discharge.

Location information to be completed at front of register:






Provider initiated testing and counseling (PICT)

(14) HIV Test Offered Tick (√) if HIV test offered under provider initiated HIV counseling and testing guidelines

(15) HIV Test performed Tick (√) if client tested for HIV/AIDS.

(16) Targeted population catego-ry

Write the target population category code listed at the bottom of the register. An individual needs to be assigned only in one category that best describe him/her. A. Female Commercial Sex workers B. Long distance drivers C. Mobile/Daily Laborers D. PrisonersE. OVC F. Children of PLHIV G. Partners of PLHIV H. Other MARPS I. General population

(17) HIV Test result (P/N) Write P in red pen if test result is Positive; N in normal color of pen if test result is negative; TB screening

(18) Screened for TB Tick (√) if a patient is screened for TB(19) TB screening result Write “N” if a patient is screened negative or “P” if a patient is screened positive

(20) Type of diagnostic evalua-tion

Write code for the type of diagnostice evaluation as: 1. Sputum smear microscopy 2. Sputum GeneXpert 3. X-ray/other imaging 4. Histopathologic test 5. other (specify) 6. Not done

(21) Result of TB screening Write code for TB screening result of the diagnostic evaluation as: TB, No TB, Not decided (ND)

Discharge

(22) Date of Discharge (DD/MM/YY)

Write the date of discharge from surgical ward, written as (EC) Day / Month / Year (DD/MM/YY)

(23) Length of stay (in days) Write the number of days in which the patient Stayed in surgical ward (Date of discharge mi-nus date of admission)

(24) Surgical ward outcome*Write ‘A’for improved, ‘B’ for same, ‘C’ for deteriorated, ‘D’ for left against medical advice (LAMA), ‘E’ for Post-operation death, ‘F’ for died without operation ‘G’ for referred to higher facility, and ‘H’ for absconded.

(25) ESV_ICD11 Write the diagnosis based on Ethiopia Simplified Version International Classification of Disease (ESV_ICD11) as it appears on hand book (do not abbreviate)


(26) Yes/No Write “Yes” if notification is given for the death occurred in the Surgical Ward Write “No” if notification is not given for the death occurred in the Surgical Ward

Finance

(27) Amount charged (birr) Write the amount of money in Birr charged by service provider during the admission

(28) Amount paid (birr or free) Write the payment presented by service recipient for the service throughout his/her stay

(29) Voucher No Write the voucher number on receipt for payment

(30) Remark Any comment suggestion, follow up that the provider would like to document.

Identification Admission Post Operation

Road Trafic Accident: 1. Pedes-

trian 2.Motorcy-

clist 3.Vehiclle occupant

Provider initiated counseling and testing (PICT)

TB Screening & Investigation Discharge

Death No-tification

GivenFinance

Remark

S/No MRN Age Sex

(M/F)

Wore-da/Sub

city

Date Added to Waiting

List (DD/MM/YY)

Date of Admis-

sion (DD/MM/

YY)

Delay for elective surgical

admission (in days)

Pre-Op-erative

Length of Stay (in days)

Pre-Op-erative

Diagnosis

OR Type: Elective (L)

or Emer-gency (E) procedure (write L or

E)

Post Op-erative

Dx (Write “SAME” if Similar Dx to preoper-ative Dx) HI

V Te

st Of

fered

(√)

HIV

Test

perfo

rmed

(√)

Targ

eted p

opula

tion c

atego

ry (co

de)

HIV

Test

resu

lt (P

or N

)

Scre

ened

for T

B (√

)

TB sc

reen

ing re

sult (

P/N)

Type

of di

agno

stic e

valua

tion (

write

co

de)

Resu

lt of T

B sc

reen

ing(co

de: T

B, N

o TB

, Not

decid

ed (N

D))

Date of Dis-charge

(DD/MM/YY)

Length of stay (days)

Surgical ward out-

come*

ESV_ICD11

Y=Ye

s/N=N

o

Amount charged

(birr)

Amount paid

(birr or free)

Vouch-er 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) (26) (27) (28) (29) (30)

Surgery RegisterName of Ward:________________________________

Targeted population category Col. 16 A. Female Commercial Sex workersB. Long distance driversC. Mobile/Daily LaborersD. PrisonersI. General population

E. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPS

Count Admission Sum Days Count Post-OP Death

Emergency SurgeryElective Surgery

Count Death Notification

Given

Count Count

Elective Surgery

PedestrianMotorcyclist

Emergency Surgery

Vehicle occupant

Surgical ward outcome for column 24A. Improved B. Same C. Deteriorated D. Left against medical advice (LAMA)E. Post-Opration deathF. Died without operationG. Referred to higher H. Absconded

ESV_ICD11 Code


Health Centre/Clinic/HospitalClients waiting for Elective Surgery

Register

Instruction for Surgical Waiting List in register


1 S/NoEnter sequentially starting from 1 until the budget year end and start again from 1 at the first day of new budget year

2 Date Write the date the patient is referred in as DD/MM/YY

3 MRN Enter Medical Record Number from individual folder

4 Full name Write the full name of the patient referred in

5 AgeWrite age of patient (if it is under 1 month enter in days, if it is under 5 year, enter in month and enter in year if it is above 5 year old)

6 Sex write sex of patient as M for male and F for Female

7 Region Write the current region of the patient

8 Sub City/zone Write the current sub city/zone of the patient

9 Woreda Write the current woreda of the patient

10 Phone number Write the correct phone number of the patient

11Department linked to (Case by Speciality)

Write the code of the department or subspeciality the patient is linked to 1. General surgery 2. Urology 3.Neurology 4. Orthopedics 5.Plastic 6. ENT 7. Opthalmology 8. Gynecology 9. Pediatrics 10. Others

12 Date client added to the waiting listThe date on which patient was added to waiting list for elcetive surgery in the form as DD/MM/YY

13Date of Client’s appointment for elective surgery The date on which patient is appointed for ellective surgery

14Date of Client’s admission for elective surgery The date on which patient is addimitted for ellective surgery

15 Number of days cleint waitedThe number of days the client waited for admission ( the time interval in days between date of admission and date added to waiting list)

16 Dropped from waiting list

Tick on the patient who was contacted but dropped from the waiting list for any reason (the patient does not want the surgery anymore, or the patient has received the service somewhere else)

17 Remark Write any thing regarding the patient in the remark section

NB: Active waiting list= Total waiting list (at the end of the month) -(Total number of patients admitted- Total number of Dropped)

This register is to be kept at Surgery DepartmentRegion Write region name where the facility is located





S/NService Date

(DD/MM/YY)

MRN Full Name Age Sex Region Subcity/ Zone Woreda Phone

number Department linked to**Date Client added to

waiting list

Date of Client’s appointment for elective surgery

Date of Client’s admission for elective

surgery

Number of days cleint

waited

Dropped from waiting list Remark

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

Sum of waiting days

Count of admitted patients

Register for clients waiting for elective surgery

** Department linked to (Col. 11): 1 = General surgery 5 = ENT 2 = Urology 6 = Opthalmology3 = Neurology 7 = Gynecology4 = Orthopedics 8 = Pediatrics5 = Plastic 10 = Others


HospitalAssistive Technology Service Tally Sheet

Woreda-------------------------- Facility Name------------------- Quarter------------------ Year------------------------

SN Data elementTally

CountTally

CountAge less 15 Age grater than 15 & Above

1 Total Registered

Male

Female

2 Physical Impairments

Male

Female

3 Mobility Impairment

Male

Female

4 Hearing Impairment

Male

Female

5 Visual Impairments

Male

Female

6 PhysicalMale

Female

7 OtherMale

Female

Assistive Technology Service Tally Sheet

Total Service Delivered

Total registered

Health Center/ Hospital Diseases Information Tally Sheet


Disease Name (ESV-ICD 11) ESV-ICD 11 code

Female Male<1 yr 1 - 4 yrs 5 - 14 yrs 15 – 29 yrs 30 – 64 yrs >=65 yrs <1 yr 1 - 4 yrs 5 - 14 yrs 15 – 29 yrs 30 – 64 yrs >=65 yrs

Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count

Diseases Information Tally SheetHealth Facility Name__________________________________________________ Year___________________________________________ Month____________


Health Center /Clinic/ Hospital Tracer Drug Availability Tally Sheet

Woreda-------------------------- Facility Name------------------- Year________ Month________ Period: -------/----- to ------/-----S/No Tracer drug list 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Overall* (1,0)

1 Medroxyprogesterone Injection

2 Pentavalent vaccine

3 Magnesium Sulphate injection

4 Oxytocine inj

5 Gentamycin injection

6 ORS+/- Zinc sulphate

7 Amoxcillin dispersable/suspension/capsule

8 Iron + folic acid

9 Albendazole/Mebendazole tablet/suspension

10 TTC eye ointment

11 RHZE/RH

12 TDF/3TC/DTG

13 Co-trimoxazole 240mg/5ml suspension

14 Arthmeter + Lumfanthrine tablet

15 Amlodipine tablet

16 Frusamide tablets

17 Metformin tablet

18 Normal Saline 0.9%

19 40% glucose

20 Adrenaline injection

21 Tetanus Anti Toxin (TAT) injection

22 Omeprazole capsule

23 Metronidazole capsule

24 Ciprofloxcaxillin tablet

25 Hydralizine injectionNote: Tick on each day, if the drug is available on the working day or leave it as blank if the drug is not available. Enter 1 in ‘’overall’’ column if the drug is available on working days and zero if it is out of stock for one or more working days in that reporting period. If the facility doesn’t give service on holidays and weekends, enter “NA” in the specifc dates and exclude the dates from the list of stock out dates.

Tracer Drug Availability Tally Sheet


Health center/Clinic/Hospital ICU Service Tally Sheet


Health Center /Clinic/ Hospital IPD Service Tally Sheet

Woreda-------------------------- Facility Name------------------- Month------------------ Year------------------------

Data element Tally count

Inpatient discharge cases

Inpatient deaths

Length of stay at discharge

Deaths in the IPD Within 24 hours

Deaths in the IPD After 24 hours


IPD Service Tally Sheet


Health Center /Clinic/ HospitalPatient/Client Attendance Tally Sheet

Data element Tally Count

Male <5 yr

Female <5 yr

Male 5-10 yr

Female 5-10 yr

Male 11-19 yr

Female 11-19 yr

Male 20-29 yr

Female 20-29 yr

Male 30-45 yr

Female 30-45yr

Male 46-65 yr

Female 46-65yr

Male 65+ yr

Female 65+ yr

Note: This tally sheet is used to analyze OPD attenedance per capita indicator and should be kept at Medical Record Unit and departments where patients do not visit Medical Record Unit to get service at follow up such as TB clinic, dressing and others

Patient/Client Attendance Tally SheetWoreda-------------------- Facility Name---------------------------------- Year------------------------ Month------------------


HospitalSurgical Waiting List Tally sheet

Woreda ________________________________________ Facility _________________________ Year__________________________ Month____________

Types of surgical services<15 years of age >15 years of age

Tally Count Tally Count

General Surgery

Urology

Neurology

Orthopedics

Plastic

ENT

Ophthalmology

Gynecology

Pediatrics

Others

Surgical Waiting List Tally sheet

NCD Registers and Tally sheets

Content / Home


Health Centre /Clinic/Hospital Cervical Cancer Screening and

Treatment Register

Purpose: This register helps to document all eligible women who received Cervical Cancer Screening and Treatment in Cervical Cancer Screening and treatment unit

Who complete the CxCa screening and treatment register? Clinicians/Service providers working in the unit would complete the CxCa register

When to complete the CxCa screening and treatment register? Immediately after a client is screened and treated in CxCa unit Data sources : All essential data elements will be abstracted from “Cervical Cancer Screening and Treatment Intake form” attached to a client chart

Column Number

Column Name Description

Client Identification

1 SN# Sequential CxCa number given for a woman during cervical cancer screening and treatment in CxCa unit

2 Visit Date (dd/mm/yy) Date client visited CxCa clinic

2 Linkage/ Referral status Code ( 0-2) Write Linkage/ Referral status : 0. Linked from the same health facility 1. Referred from other HFs 2. Referred from the community

3 Client Full Name Name of the client

3 Address Woreda, Sub city, Kebele

4 MRN Medical Record Number of a client

4 Phone # Phone number of a client

5 Age Age of a client during CxCa screening

Risk factors for CxCa

6 Marital Status Code ( 1-4) Write code of marital status of a client during CxCa visit: 1= Single 2= Married 3= Divorced 4= Widowed

6 Education Code ( 1-5) Write code of educational background of a client : 1= Illiterate 2= Can read and write 3= Elementary/junior 4= High school 5= Tertiary school

7 History of STI (Self/Partner) (Yes/No) History of STI (Self/Partner): Tick/Mark “Yes” if there was any STI history of a client or partner else tick/mark “No”

7 # of Births # of births of a woman

8 HIV Status HIV Status 1. Positive 2. Negative 3. Unknown

8 If known postive is, client on ART ART status : Click/Mark “Yes” if a client is HIV positve and started ART treatment else tick/mark “No”

CxCa Screening and Treatment

HPV DNA testing

9 Type of Visit Code( 1-3)Write code of type of visit 1. 1st time screening 2. Re-screening after previous negative result 3. Post treatment Re-screening NB: For HIV postives post treatment follow up screening should be done after 6 month of treatment and where as for the general population it should be done after 1 year.

10 HPV Sample collected Tick/Mark “Yes” if HPV DNA sample collected for screening else tick/mark “No”

10 HPV DNA Result Code (1-3) Write code of HPV DNA test result 1. Negative 2. Positive 3. Unknown(UN)

11 Collected Date (dd/mm/yy) Write HPV DNA sample collected date

11 Result Received (dd/mm/yy) Write HPV DNA result received date in CxCa unit

VIA Screening and Treatment

12VIA screenig result Code ( 0-4)

Write code of VIA screening result : 0. Not Done 1. VIA Negative 2. VIA Positive: Eligible for Cryotherapy/thermocoagulation 3. VIA Positive: Non eligible for Cryotherapy/ thermocoagulation 4. Suspicious cases for cervical cancer

VIA +ve Treatment Service Code ( 0-4) Write code of VIA treatment service provided : 0. No treatment 1. Cryotherapy 2. Thermocoagulation 3. LEEP service

13VIA Screening Date Write VIA screening performed date

VIA +ve Treatment Date Write VIA treatment provided date. This is for those client with VIA positive result

14Cytology (Pap Smear ) Sample Collected Tick/Mark “Yes” if Cytology (Pap Smear ) Sample Collected else tick/mark “No”

Cytology (Pap Smear) result Code(1-3) Write code of Cytology (Pap Smear ) Result : 1. Neg 2. ASCUS 3. > ASCUS

15 Sample Collected Date (dd/mm/yy) Write cytology ( Pap smear) sample collected date

Result Received (dd/mm/yy) Write cytology ( Pap smear) result received date

16Biopsy result Code ( 0-5) Write code of Biopsy result : 0. Not collected/Not done 1. Negative 2. CIN-1,2,3 3.

Carcinoma insitu 4. Invasive Cx Ca 5. Other specify

Treatment given based on biopsy result Treatment provided given based on biopsy result : 0. No treatment 1. Surgical treatment 2. Chemotherapy 3. Radiotherapy 4. Refered to other HF for further managment treatment 5. Status not known

17 Breast Clinical Examination Code ( 0-5) Write code of brest clinical examination: 0. Not done 1. Normal 2. Lump 3. Visible bumps 4. Nipple crusting 5. Other Specify

Risk Based HIV Testing

18 Population Category Code ( 1-7) Write code of population category : 1. FSW 2. Long distance driver 3. Mobile/Daily laborer 4. Prisoners 5. Other MARPS 6. General population 7. Other specify

19Is eligible for risk based testing? Tick/Mark “Yes” if a client is eligible for HIV test based on risk factor asessment “No” if the client is not eligible

HIV test result (P/N/UN) Write code of HIV test result : P=Positive N=Negative UN=Unknown or Not done

Referal, Appointment and Follow up Visits

20Next appointment date Write next appointment date for routine re-screening of Cx Ca screenined negative & post treatment re-screening

of Cx Ca screened positives as per the national Giudeline

Follow up re-visit date Write the follow up re-visit date as the client comes for a follow up visit . NB: Helps to identify which of the clients who were screened previosly came for re-screening visit

21Referral reason code (1-4) Write code of referral reasons. 1. For LEEP service 2. For suspicious cancer evaluation 3. For breast cancer

evaluation 4. Others

Feedback received for referred clients Code (0-2)

Feedback received for referred clients 0. Feedback not received 1. Confirmed client seen the referral HF 2. Client got all the services she could get in the referral HF

22 Remark Write remark if the are any issues that need to be documented but not mentioned in the CxCa register

Instructions on how to completed Cervical Cancer (CxCa) Screening and Treatment Register

Health Facility:_______________________________________________________ Woreda: __________________________ Zone/Sub City: __________________________Region:_____________________

Client Identification Risk factors for CxCa CxCa Screening and Treatment

Breast Clinical

Examina-tion

(Code 0-5)

Risk Based HIV Testing

Referal, Appointment and Follow-up Visits

SN#

Visit Date dd/mm/yy Client Full Name MRN

Age

Marital Status Code ( 1-4)

History of

STI (Self or Partner)

HIV status code (1-3)

Type of Visit Code ( 1 -3)

HPV DNA VIA Screening and Treatment Cytology (PaP Smear)Biopsy

Examination Code ( 0-5)

Popula-tion

Category (Code 1-7)

Eligible for risk based testing?

Next Appoint-

ment for CxCa re-screening

Referral reason Code (1-4)

Remark

HPV sample

collectedCollected Date

VIA screenng Result Code ( 1-4) VIA Screening Date

Cytolo-gy (Pap

Smear ) Sample Collected

Sample collected Date

Linkage/ Referral status:

Code (0-2)

Address (Woreda, Sub city, Kebele) Phone #

Education Code ( 1-5)

# of BirthsIf known postive; on ART ?

Screening strategy

used Code (1-3)

HPV DNA Result Code (1-3)

Result Received dateVIA + Ve Treatment

Code ( 0-4)

VIA +Ve treatment date

Cytolo-gy (Pap Smear ) Result

Code (1-3)

Result received Date

Treatment given based on biopsy result (0-5)

HIV test result Code

(P/N/ UN)

Follow up re-visit date

Feedback received for refferred clients Code (0-2)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

____/_____/______ □ Y □ N □ Y □ N ____/_____/______ ____/_____/______ □ Y □ N ____/_____/______ □ Y □ N ____/_____/______

□ Y □ N ____/_____/______ ____/_____/______ ____/_____/______ ____/_____/______

Cervical Cancer Screening and Treatment Register

Linkage/ Reffered in Status 0= Same Facility 1= Other facility 2= CommunityEducation 1= Illiterate 2= Can read and write 3= Elementary/junior 4= High school 5= Tertiary school

Marital Status 1= Unmarried 2= Married 3= Divorced 4= Widowed

HIV status 1. Pos 2. Neg 3. UK

Type of Vsiit1. 1st time screening 2. Re-screen-ing after previous negative result 3. Post treatment Re-screening

Screening strategy used 1. HPV DNA screening and VIA triage, 2. VIA 3. Cytology

HPV DNA Result 1. Neg 2. Pos 3. UN

VIA Result : 1. VIA Negative 2. VIA Positive: Eligible forCryo / thermocoagulation (TA) 3. VIA Positive: Non eligible for Cryo/thermocoagulation 4. Suspicious cases for cervical cancer

VIA +Ve Treatment 0. No treatment 1. Cryotherapy 2. Thermocoagulation 3. LEEP service 4. Other treatment given( specify)

Pap Smear Result 1. Neg 2.ASCUS 3. > ASCUS

Biopsy Result 0. Not collected/Not done 1. Negative 2. CIN-1,2,3 3. Carcinoma insitu 4. Invasive Cx Ca 5. Other

Treatment given based on biopsy result 0. No treatment 1.Surgical treatment 2.Chemotherapy 3. Radiotherapy 4. Refered to other HF for further managment treatment 5. Palliative care 6. Other specify

Population Category 1. FSW 2. Long distance driver 3. Mobile/Daily laborer 4. Prisoners 5. Other MARPS 6. General population 7. Other specify

HIV test result 1. P=Pos 2. N=Neg 3. UN

Referral reason 1.VIA screening2. Cryotherapy/ Thermal ablation3. LEEP service4. Further Evaluation & management for suspicious cases 5. Others specify

Feedback received for refferred clients Code (0-2) 0.Feedback not received 1. Confirmed client seen the referral HF 2. Client got all the services she could get in the referral HF


Health Centre /Clinic/Hospital HTN and DM Treatment Cohort

Register

Instruction on how to complete HTN and DM Treatment Cohort Register

SN Datum Comments

Identification: Personal information

11. Unique NCD Treatment Number

Write unique NCD treatment number and it should be assigned when the client is enrolled to HTN/DM care. Unique NCD treatment number assigned as:- Region number / facility type code / specific facility code / patient/client assigned number. Region number: the following code numbers are used: Tigray:- 01 SNNPR:- 07 Afar:- 02 Gambella :- 12 Amhara:- 03 Harar :- 13 Oromia:- 04 Addis Ababa :- 14 Somali:- 05 Dire Dawa :- 15 Benishangul Gummuz :-06 Sidama:-16 South West Ethiopia:-17 Facility type code: Hospital =08 Health Center = 09 Specific facility code: Each HC / hospital in the regions is coded with four digits starting from 0001. These specific facility codes are assumed to be given by regions together with federal, which means it is pre-coded and given to each facility centrally. Patient assigned number: A unique 6-digit number is given within the facility; the first patient to be enrolled for HTN/DM care in the clinic will be given 000001 Example Unique NCD Treatment No. for the first hypertension/dm patient enrolled at NCD clinic in a hospital in Tigrai: 01/08/001/000001

2 MRN Enter Medical Record Number (MRN) used on Individual medical folder

3Treatment Enrollment date (dd/mm/yyyy):

Enter the date in Ethiopian Calendar when clients are enrolled to HTN/DM care.This is the date when the client is either put on lifestyle management and/or drug treatment for the first time at the health facility.

4Patient name and Address of the HTN/DM patient

Upper space: Write the patient’s full name (individual, father, grandfather); Lower space: Write the address of patient (woreda, kebele, House No, Phone No) in column 4

5 Sex (M/F) Write the patient’s sex: M=Male; F=Female in column 5

6 Age Write the patient’s age in years in column 6.

7Treatment supporter Name and address

Write treatment supporter name and address in column 7. Upper space: Enter ‘Treatment Supporter full Name ‘ (individual, father, grandfather) Lower space: ‘Treatment supporter address ’ (woreda, kebele, House No, Phone No,)

8 Entry point:

Entry point should be written in column 8. Select and put codes from the list of ‘Entry Points” as described in the bottom of the register. E.g. if client is referred from OPD, write ‘5’ NB. Previously in care: means any hypertensive or diabetic patient who was diagnosed to have hypertension or diabetes and started either healthy life style counseling or drug treatment or both in any other public or private health facility and presented to the NCD or chronic follow up clinic or HTN/DM referral clinic for registration or enrollment to care.

Baseline clinical data at enrollment

9 Weight and height: Enter weight and height in column 9. Upper space: enter ‘Weight (in kg)’ of the client; Lower space:enter ‘Height(cm)

10 BMI (Kg/m2):Enter BMI status as Weight in Kg divided by the square of Height in Meters (kg/m2) in column 10. E.g. if client’s weight is 58 and Height is 1.60m, the Client’s BMI 22.56 kg/m2 which in normal range so write code for BMI as number 2 in column 10 as mentioned under the BMI list at the bottom of the register.

Register (HC/Private Clinic/Hospital-HTN-DM Treatment Cohort Register); kept in NCD/Chronic Follow-up/HTN-DM Referral Clinic and completed by the HTN/DM care provider.

Location information to be completed at front of register:Region Write region name where the health facility providing HTN/DM service is located.

Zone/sub-city/ woreda Write the Zone/sub-city/ woreda where the the health facility providing HTN/DM service is located.

Health Facility Write the name of the health facility where the NCD/Chronic Followup/ HTN-DM Referral Clinic is located.

Begin Date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

End Date Write the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

11, 22, 27 BP:

Enter the BP readings of the client in column 11, 22,27. Upper Space: Enter the first BP reading of the client. This is usually the second reading after two measurements are taken 1-2 minutes apart.This BP reading is the raised BP reading at OPD before the date of enrollment. If 3 measurements are taken, the average of the last two should be recorded.

Lower space: enter the second BP reading of the client.This is the BP reading on the date of confirmation of hypertension diagnosis and/or enrollment to care.This is again the second BP reading of the client after two measurements are taken 1-2 minutes apart.If 3 measurements are taken, the average of the last two measurements should be recorded.For grade 3 hypertension since hypertension diagnosis is confirmed on same date,enter the second BP reading taken 1-2 minutes apart.If 3 readings are taken, again record the average of the last two measurements.

12 Risk factors:Select and enter codes from the list of ‘Risk factors” as mentioned in the bottom of the register. E.g. if client is using tobacco, then write number 1 in column 12.

13, 23, 28

Fasting and Random blood

sugar test

Enter FBS or RBS or HBA1c result in columns 13, 23, 28. Upper space: Enter the FBS test result in mg/dl Lower space: enter RBS test in mg/dl or HBA1c test result in % if available

14CVD risk

assessment:CVD risk score should be entered in column 14.Enter the ’10 years cardiovascular disease (CVD) risk score ’from the codes mentioned at the bottom of the register e.g. if the clients CVD risk is 15% using lab based risk prediction chart , then put number ‘1’.

15 Diagnosis:

Enter the diagnosis in column 15.Enter the diagnosis of the client based on the national NCDs management protocols 2021. Upper space:Enter the diagnosis of hypertension as per the grading category mentioned at the bottom of the register e.g if the diagnosis is grade 2 hypertension, put number ‘2’ in the upper space of column 15. Lower space: enter the diagnosis of diabetes as per the types of diabetes classification mentioned at the bottom of the register e.g if the diagnosis is Type 2 diabetes, put number’5’ in the lower space of column 15. At the bottom of columb 15 always summarize the sum of hypertension and diabetic patienets diagnosed and enrolled to care when the list of patients on the same page of the register is full.

16Type of treatment

at month 0:

Enter the type of treatment for either hypertension or diabetes patients or both in column 16. Upper left space:If the type of treatment provided to hypertensive patients is life style modification or healthy life style counseling only, put ‘HLC’in the upper left space.If the type of treatment provided to hypertensive patients is drug treatment in addition to life style modification, put the code of the antihypertensive drug as mentioned in the bottom of the register e.g if the drug treatment given to the patient is amlodipine in addition to LSM, put code’1/HLC’ at the upper left space. Upper right space:If the type of treatment provided to diabetic patients is life style modification or healthy life style counseling only, put ‘HLC’in the upper right space.If the type of treatment provided to diabetic patients is drug treatment in addition to life style modification, put the code of the antidiabetic drug as mentioned in the bottom of the register e.g if the drug treatment prescribed to the patient is metformin in addition to LSM, put code’5/HLC’ at the upper right space. Lower space: enter code of the name of the drug in the lower space of column 16 if statin is given to the patient e.g if simvastatin is prescribed to the patient, put code’1’ in the lower space of column 16.

17TB Screening for

DM patients:Tick if the DM patient is screened for TB in the upper Space; Enter the screening result and result of TB diagnosis in the lower space in column 17.

18Result of TB

diagnosis Write the result TB Diagnosis

Type of treatment and Patient Outcome Evaluation Status

19, 24, 29, 32,

35

Drug / HLC HTN; Drug / HLC DM and On statin

Enter the type of treatment for either hypertension or diabetes patients or both in column 19, 24, 29, 32, 35. Upper left space: If the type of treatment provided to hypertensive patients at month 3, 6, 12, 24, or 36 is drug treatment in addition to life style modification, put the code of the antihypertensive drug as mentioned in the bottom of the register e.g if the drug treatment given to the patient is amlodipine in addition to LSM, put code’1/HLC’ at the upper left space. Upper right space: If the type of treatment provided to diabetic patients at month 3, 6, 12, 24, and 36 is drug treatment in addition to life style modification, put the code of the antidiabetic drug as mentioned in the bottom of the register e.g if the drug treatment prescribed to the patient is metformin in addition to LSM, put code’5/HLC’ at the upper right space. Lower space: enter code of the name of the drug in the lower space of column 19, 24, 29, 32, 35; if statin is given to the patient at month 3, 6, 12, 24, and 36. e.g if simvastatin is prescribed to the patient, put code’1’ in the lower space of column 19, 24, 29, 32, 35.

20, 25, 30, 33,

36RX Outcome of HTN

Enter HTN Rx Outcome based on the options given at the bottom of the register.e.g if the last two consecutive BP readings are below 140/90mmgh, put the code for controlled outcome status at end of the evaluation periods ( month 3, 6, 12, 24, or 36) as ‘1’. At the bottom of columns 20, 25, 30, 33 or 36 always summarize the number of hypertension patients with controlled status out of those diagnosed and /or registered when the list of entries on the same page is full. E.g if the number of hypertension patients registered is 4 and number of registered patients with controlled outcome status at month 3 is 1, you should summarize it as 1/4 at the bottom of column 20, 25, 30, 33, 36.

21, 26, 31, 34,

37RX Outcome of DM

Enter DM Rx Outcome based on the options given at the bottom of the register.e.g. if the last two consecutive FBS results are below130mg/dl, put the code for controlled oucome status at month 3 as ‘6’. At the bottom of column 21, 26, 31, 34 or 37 always summarize the number of diabetes patients with controlled status out of those diagnosed and /or registered when the list of entries on the same page is full. E.g if the number of diabetes patients registered is 4 and number of registered patients with controlled outcome status at month 3 is 1, you should summarize it as 1/4 at the bottom of column 21. NB: Lost follow up- means when hypertensive or diabetic patients do not report to the health center or hospital for more than 28 days after last appointment date.Dead means: A hypertension or diabetes patient who died during the course of pharmacologic or non-pharmacologic treatment. Transferred out means a hypertensive or diabetes patient who has been transferred out to another health facility during the last 3 months followup period.

38 RemarksWrite any additional information about the patient that may assist the treatment sevice provision. Enter any remarks you have during patient followup such as side effects encountered and medication switched, complications developed or patient becoming refractory to treatment in the remark section on the last column of the register.

HTN and DM Treatment Cohort RegisterHealth Facility:_______________________________________________________ Woreda: __________________________ Region __________________________Month---------------------- Cohort Year_______________

Entry Point: Col (8)1.Previously in care2 Self referral3. Referred from ART/.4. Referred from TB5. Referred from OPD6. Referred from Emerg Dep.7. Referred from ANC8. Referred from another facility9. Referred by HEW

BMI: Col (10)1.Underweight(<18.5)2.Normal(18.5-24.9)3.Over weight(25-29.9)4.Obese(30-39.9)5.Morbid Obesity(>40)

Risk factors: Col (12)1.Tobacco Use2.Physical inactivity3.Harmful use of Alcohol4.Khat Use5.Unhealthy Diet6.Others

10 years CVD risk Col (14)-Lab based risk category 1.<10% (low)2. 10%- 20% (moderate)3. >=20% ( High)Non-Lab based category 4. <10% (low to moderate)5.>=10% (High )

Diagnosis: Col (15)Types of Diabetes:1.Type I2.Type II3.GDM4 others

Antidiabetic Drugs1. NPH insulin2. Regular insulin3. Premixed insulin4.Glibneclamide5. Metformin6 Glimepiride7.Other - Specify name and dose

Antihypertensives1.Amlodipine2.Hydrochlorothiazide3.Lisinopril4.Enalapril5. Nifedipine 6. Atenolol7.ARBs8. Others - Specify name and dose

Statins1.Simvasatin2.Atorvastatin3.Rosuvastatin4.Lovastatin5. Pravastatin 6.Others - Specify nameand dose

Outcome StatusHTN Rx Outcome1.HTN Controlled2.HTN Not Controlled3.Dead4.Lost to follow up (LTF)5.Transferred out (TO) Result of TB diagnosis (17)

1.TB2. No TB3. Not decided

DM Rx Outcomes1.DM Controlled2.DM Not Controlled3.Dead4.Lost to follow up (LTF)5.Transferred out (TO)

Grading of hypertension: 1.Grade 1 2. Grade 2 3. Grade 3 (3.1.hypertensive urgency; 3.2. Hypertensive emergency)

Registration and personal information Month 0 Month 3 Month 6 Month 12 Month 24 Month 36

RemarkUnique NCD RX number

MRN

Enroll-ment date : d/mm/YY

Full Name of Patient

Sex Age

Treat-ment support-er Name

Entry point

Weight (kg)

BMI (Kg//m2

BP1

Risk fac-tors

FBS

10 years Cardio-vascular disease (CVD) Risk

Diag-nosis DM 15 Drug

/HLC HTN

Drug /HLC DM

TB screening for DM patients Drug

/HLC HTN

Drug /HLC DM

Rx Ou-come: BP1 FBS

Drug /HLC HTN

Drug /HLC DM

Rx Oucome: BP1 FBS

Drug /HLC HTN

Drug /HLC DM

Rx Oucome:Drug /HLC HTN

Drug /HLC DM

Rx Oucome:Drug /HLC HTN

Drug /HLC DM

Rx Oucome:

Full Address (Woreda, Kebele,House # and Phone #)

Home Address and Phone Number

Height (cm) BP2 RBS Or

HBA1C

HTNScreened for TB (√) Result

of TB diag-nosis

HTN DM BP2 RBS Or HBA1C HTN DM BP2 RBS Or

HBA1C HTN DM HTN DM HTN DM

DM On statin

TB screening result (P/N)

On statin On statin On statin On statin On statin

(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38)

Count HTN HTN DM HTN DM HTN DM HTN DM HTN DM

DM


Health Centre /Clinic/Hospital Mental Neurological and Substance

Use Disorder Treatment Register

Purpose: This register is used to register and follow up clients who are confirmed to have Mental, Neurological and Substance Use Disorders and are enrolled into care.

Who complete the MNS treatment register? Mental health proffessionals and mhGAP trained Service providers working in the unit would complete the MNS register

When to complete the MNS treatment register? Immediately after a client is treated in MNS unit

Cohort Month: is defined as people who are enrolled into care during the same month and year.

Data sources : All essential data elements are abstracted from patient form that is filed in the Individual Folder

Column Number

Column Name Description

Patient personal information and Treat-ment Supporter Address

1 S.No Enter sequential serial number in registration book; to be entered on client’s registration card for later identification in register in Columon-1.

2 Medical Record Number (MRN) Enter Medical record number (MRN) used on medical information folder in Columon-2.

3 Date of Enrollment (DD/MM/YY) Enter the date in Ethiopian Calendar when clients start treatment in Columon-3.

4 Age Enter age in years. If patient is under 1 year, enter age in months, followed by M.

5 Sex (M/F) Enter ‘M’ for male and ‘F’ for Female in columon-5.

6 Patient Address: Enter Home Address , Woreda nsme in the upper and , Kebele name in lower row of columon-6.

7,8,9 Treatment Supporter Address: Enter ‘Treatment Supporter Name’ in columon -7, write Woreda, Kebele of treatment supporter in collumon -8 the upper and lower row respectively, and phone number of treatment supporter in columon-7,8,9.

Baseline Clinical Data at Enrollment

10 Entry point (Code:1-5 Write the code the person’s means of access to mental health services as 1- for Previous in care, 2- for Self referral, 3- for Referred from OPD, 4-for reffered from another health facilities and 5-for referred from HEWs in Columon-10

11 Screening other Health conditions (Code:1-6)

Write code for screening the other Health Conditions (1-6) and separte with comma for which it has more than one screening status, as 1.TB, 2.HIV,3.DM,4.Hypertension,5.Cervical Cancer 6. others in Columon-11

12 Diagnosis: ( Code:1-16)

Write code of the Diagnosis(1-16) as 1-Schizophrenia, 2- Schizoaffective Disorders, 3-Other Psyhcosi, 4-Depressive Disor-ders, 5-Bipolar Disorders,6-Epilepsy,7- Dementia , 8-Alcohol Use Disorders,9- Other Substance Use Disorders, 10-Autistic Disorders, 11-for Other Autistic Spectrum Disorders, 12-Intellectual disability, 13- Learning and other dev’tal Disorders, 14-Attention deficit hyperactivity disorder (ADHD), 15-Conduct and Oppositional Disorders, 16-Others and if the diag-nosis result shows more than one disorder, write the disorder code and separet them with comma in Columon-12.

13 New Tick(√) on “New” if the patient is New or first visit for MNS service on columon-13

14 Known Tick(√) on “Known” If the patient is known (have more than one visit for MNS services) or on follow up on columon-14

15, 36 EEG done (Yes/No) Indicated whether the EEG (Electro encephalograph recording) is done or no. “Yes” if is done otherwise write “No” in the last investigation at 0 months,and 24 months (column 15 & 36)

16 Risk Assessement (Code:1-3) make Tick(√) mark on the upper row -if the patient has likelihood of suicide, Tick(√) mark on homicide in middle row and Tick(√) on the lowere row if the patient has likelihood of self neglect in columon-16

17 Treatment; (Code: A, B, C, D, E, and/or F)

Write the Prescribed Medication Code number for the Treatment in the Month 0 ( A-F) A- antipsychotic 1-9, B.Antide-presant 1-7, C. Anticonvesant/Mood stablizers 1-7, D. Anxiolitics 1-5, E. Addiction Treatment 1-4, F. Non Pharmacological Treatment 1-4 in columon-17. For instance: If the given treatments are Amitriptyline and Psychological Intervention, then write Code: B, F.

Follow up Data

18, 23, 28, 33, 39 Treatment; (Code: A, B, C, D, E, and/or F)

Write the Prescribed Medication Code number for the Treatment in the Month 0 ( A-F) A- antipsychotic 1-9, B.Antide-presant 1-7, C. Anticonvesant/Mood stablizers 1-7, D. Anxiolitics 1-5, E. Addiction Treatment 1-4, F. Non Pharmacological Treatment 1-4 in columon-18, 23, 28, 33, 39, . For instance: If the given treatments are . Thyamine and . Rehabilitation Therapy, then write Code: E, F.

19,24, 29, 34, 40 Reason for Medication Change (Code 1-5)

If there is treatment medication change, Write the reasonsof medication change 1-for side effects, 2-for misdiagno-sis,3-ineffectiveness, 4-inaccessibility, 5-not afordable in Columons 19,24, 29, 34, 40

20, 25, 30, 35, 41 Side Effects(Code 1-9)

Write the code for side effects on patients to their periodic follow up (i.e months 0-3, 4-6, 7-12, 24, 36) if any 1.acute dystonia 2 Akathsia 3 Tremer 4. Cog- wheeling 5 Muscular rigidity 6. Tardive dyskinesia 7. Weight gain, 8. Cardiac side effects and 9. others and If there is more than one side Effects , Write the Code Number and separate them with Comma in olumon -20, 25, 30, 35, 41.

21, 26, 31, 37, 42 Adherence (Code 1-3) Write code for adherence status at each 6 months and 1 for good( (>95% of the doses are taken), 2 for fair(85-94% of the

doses are taken) and 3 for poor(<85% of the doses are taken) in columons -21, 26, 31, 37, 42.

22, 27, 32, 38, 43 RX Outcome Status (Code 1-5

Write the code for the RX outcome status for the Month of 3, 6,12,24 &36 with 1 for controled (the symptoms of MNS disorder are not observable/managed), 2 Not controled( if the symptoms of MNS disorder are observable/not managed), 3 dead , if the patient is reported as died, 4 lost if the patient is not coming for follow up appointment, 5 To-transfer out for furter health service or refered back to his home near Health facilities) in Columons- 22, 27, 32, 38, 43

44 Remark Write remark if the are any issues that need to be documented but not mentioned in the MNS register in Columon -44

Note

Psychological Intrvention: includes Psychoeduction, Psychological counseling, Psychotherapy

Rehabilitation Therapy: includes physical, occupational, speech, music or recreational therapiers

Instructions on how to completed mental health, neurological and substance use disorder (MNS)Treatment Registration

S.N

o

Patient personal information and Treatment Supporter Address Baseline Clinical Data at Enrollement Patients Follow up Data

Remark

Patient personal information Treatment Supporter Address: Month-0 Months 3 Months 6 Months 12 Months 24 Months 36

MRN

Date of Enrollment (DD/MM/

YY)

Age Sex (M/F)

Patient’s Address: (Woreda/ Kebele)

Treatment Sup-porter Name

Woreda/ Kebele,

Phone Number

Entry point

(Code : 1-5)

Screen-ing

Other Health Condi-tions (code :1-6)

Diag-nosis

(code: 1-16) N

ew (√

)

Know

n (√

) EEG done (Yes/No)

Risk asses-

sement (Code 1-2)

Treat-ment

(Code: A, B, C, D, E, and/or F)

Treat-ment

(Code: A, B, C, D, E, and/

or F)

Reason for

Treat-ment

Change (Code 1-5)

Side Effects (Code:

1-9)

Adher-ence

(Code : 1-3)

RX Out-come Status (Code :

1-6)

Treat-ment

(Code: A, B,

C, D, E, and/or F)

Reason for Treat-

ment Change (Code 1-5)

Side Effects ( code:

1-9)

Adher-ence

(Code : 1-3)


1-6)

Treat-ment

(Code: A, B,

C, D, E, and/or F)

Reason for

Treat-ment

Change (Code 1-5)

Side Effects (Code:

1-9)

Adher-ence

(Code: 1-3)


1-5)

Treat-ment

(Code: A, B,

C, D, E, and/or F)

Reason for

Treat-ment

Change (Code 1-5)

Side Effects (Code:

1-9)

EEG done (Yes/No)

Adher-ence

(Code : 1-3)


1-6)

Treat-ment

(Code: A, B,

C, D, E, and/or F)

Reason for

Treat-ment

Change (Code 1-5)

Side Effects (Code:

1-9)

Adher-ence

(Code: 1-3)

RX Out-come Status (Code:

1-6)

(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44)

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

___/____/_____

Count

Mental

Neurolog-ical

Substance

Dev’tal & Bhr

Mental Neurological and Substance Use Disorder Treatment RegisterRegion ____________ Woreda _______ Name of Health Facility ____________________________________Cohort Year__________ Month________

Entry Point Col (10), Code:1-51. Previously in care2. Self referal 3. Reffered from OPD4. Referred from another Facilities5. Referred by HEWs

Screening for Other Health Conditions (Col-11) Code:1-61. TB 2. HIV3. DM 4. Hypertention 5. Cervical CA6. others

Diagnosis (Col-12), Code:1-161. Schizophrenia 2. Schizoaffective Disorders 3. Other Psyhcosis 4. Depressive Disorders 5. Bipolar Disorders 6. Epilepsy 7. Dementia 8. Alcohol Use Disoders 9. Other Substance Use Disodrs 10. Autistic Disorders 11. Other Autistic Spectrum Disorders 12. Intellectual disability 13. Learning and other dev'tal Disorders 14. ADHD 15. Conduct and Oppositional Disorders 16.Others

Risk assessment (col-16), Code:1-3 1.Suicide 2.Homicide3. Self neglect)

Reseans for Treatment Change (19, 24, 29, 34); Code 1-51. Side Effects 2. Medication Ineffectiveness3. Inaccessibility 4. Not affordable 5. Other (specify)

Treatment in the Month of 0,3 ,6,12,24,36 (17, 18, 24, 28, 33, 39); Code: A, B, C, D, E, and/or F)A. Antipsychotic: 1. Risperidone 2. Olanzapine 3. Haloperidol 4. Chlorpromazine 5. Fluphenzine Decanoate 6. Thioridazine 7. Clozapine 8. Trifluoperazine 9. Other: specify___ B. Antidepressants : 1. Amitriptyline 2. Imipramine 3 Sertraline 4. Fluoxetine 5. Clomipramine 6.Benzhexol 7. Others____ C. Anticunvelsants / moodstabilizer 1. Sodium valporate 2. Carbamezapine 3. Lithium 4. Phenytoin 5. Phenobarbitone 6. Ethosuxemide 7.others D. Anixioletics 1. Diazepam 2. Bromazepam 3. Lorazepam 4. Clonazepam 5. Others E. Adiction Tratment: 1. Thyamine 2. Vitamin B Complex 3. Multi Vitamins 4. others F. Non Pharmacological: 1. ECT 2. Psychological Intervention 3. Social Support 4. Rehabilitation Therapy (physical, occupational, speech, music or recreational)

Side Effects (23, 28, 35, 42, 50), Code 1-9 1. Acute dystonia 2 .Akathsia 3 Tremer 4. Cog- wheeling 5 Muscular regidity6. Tardive dyskinesia 7. Weight gain, 8. Cardiac side effects,9. Others

Adherence (Col-24, 29, 36, 44, 51), Code 1-31. Good 2. Fair 3. Poor

Rx Outcome Status (Month 3, 6,12,24 &36) Col-25, 30, 37, 45, 52; Code 1-6 1. Controlled 2. Not control 3. Dead 4. Lost 5.TO

NTDContent / Home


Health Centre /Clinic/Hospital Leishmanises Register

Column Datum CommentsIdentification: Personal Information

1 S.No WriteSequential serial number in registration book

2 Date of admission (DD/MM/YY) Write Date of Admission as Day / Month / Year (DD/MM/YY)(EC)

3 MRN Write Unique individual identifier used on integrated medical records folder at HC and hospital

4 Name / Father, grandfather name Write the patient’s first name in the upper space and father’s and grandfather name in the lower space

5 AgeIf the patient is less than 5 years of age, enter the patient’s age in months -MM For example, a 4-month-old child is entered as 4M. If the patient is 5years of age or older, enter the patient’s age in years -YY. For example, a 6-year-old child is entered as 06.

6 Sex(M/F) Write sex of patient as M for male and F for Female7 Woreda/Kebele Name Write Patient Woreda on the upper row and the patient, Kebele in the lower row(for ingenious case)

8 Country Write name of the Country for imported case i.e. the patient come from neighboring country of the health facil-ity

9 Travel History (Y/N) Write Travel history to VL endemic area as: Y for yes,N for No based on the response of the patient about his/her travel to known Leishmaniases endemic areas.

10 No. of Months sick before admission Write the number months the patient is sick before admission

11 Pregnancy(Y/N/NA) / TrimesterIn the Upper row : If the patient is female, document her pregnancy status Y for ‘Yes’ ,N for ‘No’ and ‘NA’ if not applicable (in case of male and children) In the lower row : write the trimester as 1st, 2nd or 3rd.

Diagnosis Tick (ü) the type of the case diagnosed it could be: Primary VL, Relapse VL, PKDL, CL or MCLVL (Viseral Leishmaniasis)

19-21 Lab Result (DAT/RDT/ Aspirate)

§ Write the Lab result : § VL diagnostic lab result as: DAT: P for Positive, N for Negative, or BL for borderline.§ RDT ( RK39): P for Positive or N for Negative, § Aspirateresult with the parasitic load of spleen aspirate/bone marrow aspirate/lymph node aspirate as0, +1, +2, +3, +4, +5, +6)

22 Nutritional Status (Normal, MAM ,SAM)

Write the nutritional status of the KA /VL patient as follows : - Normal if BMI>18.5, for adult and Wt/Ht >80%, MUAC>12cm for children, -MAM (Moderate Acute Malnutrition) if BMI is between 16 and 18.5 inclusive for adult and Wt/Ht between 70% to 80% inclusive or MUAC between 11cm and 11.9cm for children or -SAM if BMI < 16, for adult and Wt/Ht <70% or MUAC <11cm for children or Nutritional edema

23 concomitant and other OIWrite concomitant infection(s)as 1.Tuberculosis, 2.Pneumonia, 3.Skin infection, 4 Sepsis5.Others……..

24 Drug Side EffectWrite drug side effect as 1.Cardiotoxicity, 2. Pancrearatitis3.Nephrotoxicity, 4. Hepatotoxicity, 5. Others6. Unknown

25 Treatment Regimen Write VL drug given to the patient as 1=SSG+PM, 2=SSG, 3=Ambisome ,4=Ambisome + Miltefosine 6=Oth-er, specify

26 Initial treatment outcome Write the initial treatment outcome as 1=Cured, 2=referral 3=Defaulted, 4=Relapse, 5=Died 5=Treatment Failure

27 Conformation of Cure (C/P) Write Conformation of Cure ‘C’ for clinical or ‘P’ for parasitological28 Date of Discharge (DD/MM/YY) Write Date of Discharge as Day / Month / Year (DD/MM/YY)(EC)CL (Cutaneous Leishmaniasis)29 Test Result by Direct Exam.(P,/N/In) Write CL Test Result by Direct Exam as P=Positive, N=Negative or In=Inconclusive30 Size of Lessions (<4cm, >4cm) Write Size of the CL Lesion(s)if measured(categorized is under <4cm or >4cm )31 Time elapsed (in days) Write the number of days elapsed between onset of the CL symptoms and its diagnosis

32 Treatment Regimen Write CL treatmentgiven to the patient as 1=MeglumineAntimonial(glucantime), 2=SSG, 3=cryotherapy 4= SSG+Cryotherapy 5=Other specify

33 Date of Discharge (DD/MM/YY) 34 Initial treatment outcome35 HIV test offered (√) Tick (√) if HIV test offered under provider initiated HIV counseling and testing guidelines36 HIV test performed (√) Tick (√) if client tested for HIV/AIDS and received test result37 HIV Test results (R/NR) Write R in red pen if test result is Positive; NR in normal color of pen if test result is negative38 Remark Write any additional remarks about patient and/or operation.

INSTRUCTIONS FOR LEISHMANISES REGISTERLocation information to be completed at front of register:

Description


Zone/Sub-City /Woreda Write Zone/Sub-City /Woreda name where the facility is located.Name of Health Facility Write the name of the health facility where the service was provided.Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Write the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

Personal Identification Address

Travel Histroy (Y/N)

No of Months

sick before admis-

sion

Pregnan-cy (Y/N/

NA)

Diagnosis VL (Viseral Leishmaniasis) CL (Cutaneous Leishmaniasis) PITC

RemarkS.No

Date of admis-

sion (DD/MM/YY)

MRN

Name

Age Sex (M/F)

Woreda/ Kebele

Country (imported

case )

VL CL MCL Lab Re-sult Nutri-

tional Status

(Normal, MAM ,SAM) Co

nc-o

mita

nt O

IDr

ug S

ide E

ffect

Trea

tmen

t Reg

imen

Initial treat-ment

outcome

Confi

rmat

ion

of cu

re(C

/P)

Dat

e of D

ischa

rge (

DD/

MM/Y

Y)

Skin test re-sult (P/N/In)

Size

of L

essio

ns (<

4cm

, >4

cm)

Tim

e elap

sed

(in d

ays)

Tr

eatm

ent R

egim

en

Date of Dis-charge

(DD/MM/YY)

Initial treat-ment out-

come

HIV

test

offe

red

(√)

HIV

test

per

form

ed (√

)HI

V Te

st re

sults

(R/N

R)

Father , Grandfather Name Trimester

Prim

ary (√)

Re

lapse

(√)

PKDL

New

(√)

Relap

se (√

)Ne

w (√

)Re

lapse

(√)

DAT(

P/N/

BL)

RDT(

P/N)

Aspi

rate

(0-+

6)

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 26 27 28 29 30 31 32 33 34 35 36 37 38

LEISHMANISES REGISTER YEAR 20______

VL Regimen code: (Col. 25)1=SSG+PM, 2=SSG, 3=Ambisome ,4=Ambisome + Miltefosine

CL Regimen code (Col. 32)1=Megilumine Antimoniate (glucantime), 2=SSG, 3=Other Specify

Treatment Outcome col (27) & col (34)1=Cured, 4=Relapse2=referral 5=Died 3=Defaulted, 6=Treatment Failure

Conc-omitant OI @Column 23 1.Tuberculosis,2.Pneumonia,3.Skin infection,4. Sepsis5.Others……..

Drug Side Effect @Column 24 1.Cardiotoxicity,2.Pancrearatitis3.Nephrotoxicity,4.Hepatotoxicity,5. Others6. Unknown


Hospital Trachomatous Trichiasis (TT)

Surgery Register

SN Datum Description

1 Serial number Sequential serial number in registration book; to entered on client’s registration book for later identifica-tion in register

2 Reg. Date Write the date the client registered, written as (EC) Day / Month / Year (DD/MM/YY)

3 Medical Record Number (MRN) Unique individual identifier used on medical information folder, for HC & Hospital

4 Name in full Upper space: Write individual name and Lower space: Write father, grandfather name

5 Age Age in complete years

6 Sex Write “M” for Male or “F” for Female

7 Address Write Kebele, Gott, HDA, House No (please write the name of woreda if the patient address is different from the woreda where the facility exists)

8 Modalities Write one of the three modalities for service provision (Static, Outreach and dedicated mobile team)

9 to 12Diagnosis-check as appro-priate(√)

Check the appropriate diagnosis (RUL-Right Upper Lid, LUL-Left upper Lid, RLL-Right Lower Lid, LLL-Left Lower Lid)

13 to 16 Post op Follow up write code

Write the post op outcome at 7-14 days and 3-6 month follow up: use the following

7-14 days post op follow up 3-6 month post op follow up

1. Good result only Suture removed 1. Good correction

2. Eyelid closure defect: 2. Trichiasis: Eyelashes touching the eye.

3. Cellulitis 3. Infection: Tearing or discharge from theoperated eye.

4. Local infection:

4. Granuloma: Feeling of a foreign body in the eye, accompanied by a visible lump on the inner side of the eyelid, which causes discomfort.

5. Lagophthalmos: When the eyelid is closed, a portion of the eye is visible.

17 Treatment offered Write code of the post op treatment 1=Zithromax 2=TEO

18 HIV Test Offered (√) Tick if HIV test is offered under provider initiated HIV counseling and testing guidelines

19 HIV Test performed (√) Tick if client tested for HIV/AIDS.

20Targeted population category

Fill column 20 selecting from the list of target population category listed, an individual needs to be as-signed only in one category that best describe him/her. A. Female Commercial Sex workers B. Long distance drivers C. Mobile/Daily LaborersD. Prisoners E. OVC

21 HIV Test result (P or N) Write “P” for the Positive or “N“ for the Negative

22 Name of IECW/ Surgeon Write full name of surgeon etc

23 Remark Any comment, suggestion etc the provider would like to document

INSTRUCTIONS FOR TT REGISTER HEALTH CENTER / HOSPITAL

The TT register is completed from patient card by service provider (TT surgeon)Location information to be completed at front of register:

Region Write the region where the facility is located

Zone Write the zone where the facility is located

Woreda/subcity Write the woreda/subcity where the facility is located

Health Facility Write the name the health facility where TT operation service is provided

Register begin Date Enter the date of the first entry in the register/write as (EC) Day/Month/Year (DD/MM/YY)

Register End Date Enter the date of the last entry in the register/write as (EC) Day/Month/Year (DD/MM/YY)

F. Children of PLHIV G. Partners of PLHIV H. Other MARPS I. General population

Identification

Modalities (Static, Mobile,

Outreach)

Diagnosis-check as appropriate (√)

Post op Follow up * write code

Trea

tmen

t offe

red

(1=Z

ith-

rom

ax T

ab*;

TEO

=2)

Provider initiated counseling and testing (PITC)

Name of IECW/ Surgeon Remark

Personal information Address Upper Lid Lower Lid 7 - 14 days 3 - 6 Month

HIV

Tes

t Offe

red

(√)

HIV

Tes

t per

form

ed

(√)

Targ

eted

pop

ula-

tion

cate

gory

(cod

e)H

IV T

est r

esul

t (P

or N

)

S. N.

Reg. Date (DD/MM/YY) MRN Name in full (individual) (fa-

ther, grandfather) Age SexWoreda , Kebele, Gott, HDA, House

NoRUL LUL RLL LLL RUL/

RLLLUL/LLL

RUL/RLL

LUL/LLL

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23)

Post op Follow up * (Col 13-16)

7-14 days post op follow up 3-6 month post op follow up

1. Good result only Suture removed 1. Good correction

2. Eyelid closure defect: 2. Trichiasis: Eyelashes touching the eye.

3. Cellulitis 3. Infection: Tearing or discharge from theoperated eye.

4. Local infection:4. Granuloma: Feeling of a foreign body in the eye, accompanied by a visible lump on the inner side of the eyelid, which causes discomfort.

5. Lagophthalmos: When the eyelid is closed, a portion of the eye is visible.

Targeted population category (Col. 20)A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPSI. General population

Trachomatous Trichiasis (TT) Surgery Register

RMNCH Registers and Tally sheets

Content / Home


Health Centre /Clinic/Hospital Family Planning Register

SN Datum CommentsIdentification: Personal information

1 S.N Sequential serial number in registration book; to be entered on client’s registration card for later identification in register

2 MRN Medical Record Number Unique individual identifier used on medical information folder, for HC and hospital.

3 Name of client Write Name of client4 Age Age in years5 Sex(M/F) M=Male; F=Female

Family Planning services:Registration

6 Reg. date(DD/MM/YY)

Date client registered in this registration book, written as Day / Month / Year (DD/MM/YY) (EC)

7 New acceptor (√)Tick (√) if client is new acceptor at the time of registration. A new acceptor is someone who has not received a contraceptive method from a recognized Provider before registration.*

8 Repeat acceptor (√)

Tick (√) if client is repeat acceptor at the time of registration. A repeat acceptor is someone who is not a new acceptor; in other words, a repeat acceptor has received a contraceptive method from a recognized Provide before registration.

HIV Testing and Counseling

9 HIV test offered(√) Tick (√) if HIV test offered under provider initiated HIV counseling and testing guidelines

10 HIV test performed(√) Tick (√) if client tested for HIV/AIDS and received test result

11 HIV Test results(P/N) Enter P in red pen if test is Positive; N in normal color of pen if test is negative;

12HIV specific contraceptive counseling / Contraceptive offered(√)

Tick (√) if HIV specific contraceptive counseling / methods offered.

13 HIV Positive and linked to ART(√) Tick (√) if the client is positive and linked to ART clinic

The register is kept in FP room. Completed by Family Planning Service ProviderLocation information to be completed at front of register:


Woreda / Sub-City Write the woreda/sub-city where the facility is located.

Name of Health Facility Write the name of the health facility where the FP services are provided.

Register begin date Enter the date of the first entry in the register, written as (EC) Day / Month /Year (DD/MM/YY)

Register end date Enter the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

INSTRUCTIONS FOR FAMILY PLANNING REGISTRATION ATHEALTH CENTER / CLINIC / HOSPITAL

14 Targeted population category Write code

Write code for column 14 selecting from the list of target population category listed, an individual needs to be assigned only in one category that best describe him/her. A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPSI. General population

15 Td status checked(√) Tick (√) if Td status checked.

16 Contraindications for IUD

Tick (√) if one of following conditions present Client (or partner) has other sex partners Sexually transmitted genital tract infections(GTI) within the last

3 months or other chronic STI (eg HBV, HIV/AIDS). Pelvic infection (PID) or ectopic pregnancy(within the last 3

months) Heavy menstrual bleeding (twice as much or twice as long as

normal) Severe menstrual cramping (dysmenorrhea) requiring

analgesics and/or bed rest. Bleeding/spotting between periods or after intercourse Symptomatic valvular heart disease other

17 Visit No (1-5) Visit number in the current year

18 Visit Date Date of visit, written as (EC) Day / Month / Year (DD/MM/YY)

19 Contraceptive provided

Contraceptive method provided (record modern methods only) Abbreviate type as follows:MaC- Male CondomFeC- Female CondomOC- Oral ContraceptiveInj- InjectableEC- Emergency ContraceptionDiaph-DiaphragmIUCD- Intrauterine Contraceptive DeviceImp -Implant TL - Permanent Contraception Method for Tubal Legation V - Permanent Contraception Method for Vasectomy

20 Appointment date Follow up appointment for each method

21 Remarks Any additional suggestions, comments

Identification Family Planning and contraceptive services

Personal information Registration HIV Testing and Counselling

Td st

atus c

heck

ed (√

)

Contr

aindic

ation

for I

UCD

(√)

Clinical exam and contraceptive services provided Follow-up and remark

S.N MRN Name of Client Age Sex (M/F)

Reg. date (DD/MM/YY)

New

acce

ptor (

√)

Repe

at ac

cepto

r(√)

HIV

Test

offer

ed (√

)

HIV

Test

perfo

rmed

(√

)HI

V Te

st Re

sult

(P/N

)HI

V sp

ecific

Con

tra-

cepti

ve co

unse

ling

offer

ed (√

)

HIV

Posit

ive an

d lin

ked t

o ART

(√)

Targ

et po

pulat

ion

Categ

ory w

rite co

de

Visit

No. Visit date

(DD/MM/YY)Contraceptive

providedAppointment

dateRemark/Name

&signature

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

New Rep

Family Planning Register

Use Abbrevation For (Col. 19) Mc=Male condom FeC=Female condom OC=Oral contraceptive Ec=Emergency Contraceptive Inj=Injectabile

Imp=Implant IUCD=Intrautrine device TL=Tubaligation Vas=Vasectomy Oth=Others

Targeted population category (Col. 14) A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. Prisoners



Health Centre /Clinic/Hospital Long Acting Family Planning Removal

Register


1 S.N Sequential serial number in registration book; to be entered on client’s registration card for later identification in register

2 MRN Medical Record Number Unique individual identifier used on medical information folder, for HC and hospital.

3 Name of client4 Age Write age in years

Family Planning Long acting Removal services:Registration

5 Reg. date(DD/MM/YY)

Write Date client registered in this registration book, written as (EC) Day / Month / Year (DD/MM/YY)

6 Date of insertion Write Date of insertion Day / Month / Year (DD/MM/YY)

7 Type of LAFP used

Write Contraceptive method provided (record modern methods only) write type of as contraceptive followsImplanon - Implanon ImplantSino-Implant- Sino ImplantJadell -Jadelle ImplantIUD- Intrauterine Contraceptive Device

8 Place of LAFP received (write code)

Write code for type of facility LAFP provided abbreviate as follows:Within facility WIOut of FacilityHospital 1Health center 2Health Post 3Private clinic 4

9 Date of Removal service provided Date of removal written as (EC) Day/Month/Year(DD/MM/YY

10 LAFP method duration used in month

Write duration of method used in month (if the client used only one month we can put =1, if it is two month =2 and so on )

11 Reasons of removal

Write code for reasons of removal a) On recommended timeb) Side effectc) Want to get pregnantd)Misconceptione) Others

Counseling and testing

12 HIV test offered (√) Tick (√) if HIV test offered under provider initiated HIV counseling and testing guidelines

13 HIV test performed (√) Tick (√) if client tested for HIV/AIDS and received test result

14 HIV Test results (P/N) Inter P in red pen if test is Positive; N in normal color of pen if test is negative

INSTRUCTIONS FOR LONG ACTING FAMILY PLANNING REMOVAL REGISTRATION AT

HEALTH CENTER / CLINIC / HOSPITAL

The register is kept in FP room (HC/Clinic/Hospital), Completed by Family Planning Service ProviderLocation information to be completed at front of register:



Name of Health Facility Write the name of the health facility where the FP Long Acting Removal services are provided.Register begin date Enter the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register end date Enter the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

15 HIV specific contraceptive counseling offered (√) Tick (√) if HIV specific contraceptive counseling offered.

16 Positive and linked to ART (√) Tick (√) if the client is positive and linked to ART

17 Targeted population category write code

Write code Fill column 17 selecting from the list of target population category listed, an individual needs to be assigned only in one category that best describe him/her. A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPSI. General population

18 Post Removal Contraceptive provided

Contraceptive method provided (record modern methods only) Abbreviate type as follows:MaC -Male CondomFeC -Female CondomOC -Oral ContraceptiveInj -InjectableEC -Emergency ContraceptionDiaph -DiaphragmIUCD- Intrauterine Contraceptive DeviceImp -Implant

19 Remarks Any additional suggestions, comments…

Identification Long Acting Family Planning Removal services

Personal information Registration

Date

of R

emov

l ser

vice

pr

ovid

ed (D

D/M

M/Y

Y)

LAFP

met

hod

dura

tion

used

in m

onth

Reas

on fo

r Rem

oval

Counseling and testing

Post

Rem

oval

Con

tra-

cepti

ve p

rovi

ded

RemarkS.N MRN Name of Client Age Reg. date

(DD/MM/YY)

Date

of i

nsre

tion

(DD/

MM

/YY)

Type

of L

AFP

used

Plac

e of

LAF

P re

-ce

ived

use

cod

e

HIV

Test

offe

red

(√)

HIV

Test

per

form

ed

(√)

HIV

Test

Res

ult

(P/N

)HI

V sp

ecifi

c co

un-

selin

g /

met

hods

off

ered

(√)

Posi

tive

and

linke

d to

ART

Targ

et p

opul

ation

Ca

tego

ry w

rite

code

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

0-6 month >6 month

Within facility WI Implanon

Out of Facility Sino-Implant

Hospital 1 Jadell

Health center 2 IUD

Health Post 3 Others

Private clinic 4 Total Removal

Long Acting Family Planning Removal Register

Reason for Removal (Col. 11)a) On recommeded time b) Side effect c) Want to get pregnant d)Misconception e) Others


Targeted population category (Col. 17)A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVC

Place of LAFP received use code (Col. 8)


Health Centre /Clinic/Hospital Antenatal Care Register


Zone/Sub-City /Woreda Write Zone/Sub-City /Woreda name where the facility is located.

Name of Health Facility Write the name of the health facility where the service was provided.



S.N Datum Comments 1 S.N Write sequential serial number in the registration book

2 Name/Kebele* Write mother name in upper row and Kebele in the lower row *If mother comes from other woreda write the woreda and Kebele

3 MRN Write unique individual identifier used on medical information folder

4 Age Write the age of the women in years

5 LNMP (DD/MM/YY) Write last normal menstrual period of the women in day/month / year ( DD/MM/YY)

6 EDD (DD/MM/YY) Write the expected date of delivery in day/month /year (DD/MM/YY)

7 Contact number Specifies the contact number based on Antenatal Care Contact

8 Date of Contact Write the exact date of the Contact ( DD/MM/YY)

9 Gestational Age in weeks (GA) Write gestational age of the Pregnancy in weeks

10 Ultrasound performed within 24 Weeks of GA Write “Y” if she has ultrasound evaluation within 24 weeks (including the 24th week), Write “N” if not performed within 24 weeks.

11 Syphilis test result

( R/NR/ND)

Write “R” for women tested Reactive for syphilis and write “NR” for women tested Not Reactive for syphilis ND= Not Done if syphilis test is not done

12 Syphilis Treatment Given (√) Tick (√) if syphilis treatment is given.

13 Hepatitis B test result

( R/NR /ND)

Write “R” with red pen if the test result is Reactive and write NR in ordinary pen if the test result is Not Reactive and ND= Not Done if Hepatitis B test is not done

14 Hepatitis B Treatment Given (√) Tick (√) Hepatitis B Treatment is Given

15 Hepatitis B prophylaxis given (√) Tick (√) Hepatitis B prophylaxis is Given

16 Td provided (dose number) Write actual dose of Tetanus + Diphtheria (Td) the women received

17 IFA/Ferrous sulphate with folic acid provided(Tabs) Write the amount of tablets provided during ANC visit

18 Deworming provided (√) Tick (√) for women received deworming at 2nd or 3rd trimester pregnancy

19 MUAC (cm) Write the measurement value of MUAC in centimeter(cm)

20 HIV Test accepted(√) Tick (√) if the women accepted HIV Test.

21 HIV test result(P/N) Write P in red pen if HIV test result is Positive; N in normal pen color if HIV test result is negative22 Targeted population category write code Write the code for target population category listed below the register. An individual needs to be assigned

only in one category that best describe him/her A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPS

I. General population

23 HIV Test results received with post test counseling Tick (√) if the woman received post-test counseling

24 HIV Positive Linked to PMTCT Tick (√) if the woman is positive and linked to PMTCT.

25 Known HIV positives (transferred from ART) Tick (√) if the woman is known HIV positive and Linked from ART

26 HIV Test accepted(√) Tick (√) if partner accepted HIV test

27 Partner HIV Test result (P/N) Write P in red pen if Partner HIV test result is Positive; N in normal pen color if Partner HIV test result is negative

28 Targeted population category Refer above (column 21)

29 HIV Positive partner Linked to ART Tick (√) if the partner is HIV positive and linked to ART.

Counseling30 Counseled on Danger Signs ( √) Tick (√) if the woman is counseled on Danger Signs

31 Counseled on Maternal Nutrition( √) Tick (√) if the woman is counseled on Maternal Nutrition

32 Counseled on Early Childhood Development /ECD/ Tick (√) if the woman is counseled on ECD

33 Counseled on infant feeding (√) Tick (√) if the woman is counseled on infant feeding

34 Counseled On family planning(√) Tick (√) if the women received advised on family planning

35 Remark/Appointment/Action Write date of appointment and you may write any case which is not included in this registration book and any actions taken.

INSTRUCTIONS FOR ANTENATAL CARE REGISTRATIONThe register is kept in ANC room (HC/Clinic/Hospital), completed by antenatal care provider

Location information to be completed at front of the registry

Personal information ANC Contact HIV Assessment and Followup Partner Test Counseling on

Rem

ark/

App

oint

men

t

S.N Name/Kebele* MRN Age

LNM

P (D

D/M

M/Y

Y)

EDD

(DD

/MM

/YY)

Cont

act N

umbe

r

Dat

e of

Con

tact

(D

D/M

M/Y

Y)

Ges

tatio

nal A

ge in

wee

ks (G

A)

Ulta

soun

d pe

rfor

med

with

in

24 W

eeks

of G

A (Y

/N)

Syph

lis te

st re

sult

(R/

NR/

ND

)

Syph

lis tr

eatm

ent g

iven

(√)

Hep

atitis

B te

st re

sult

(R

/NR/

ND

)

Hep

atitis

B tr

eatm

ent g

iven

(√)

Hep

atitis

B p

roph

ylax

is g

iv-

en(√

)

Td p

rovi

ded

(dos

e nu

mbe

r)

IFA

/Fer

rous

sul

phat

e

with

folic

aci

d pr

ovid

ed (

tabs

)

Dew

orm

ing,

pro

vide

d (√

)

MU

AC (c

m)

HIV

Tes

t acc

epte

d (√

)

HIV

Tes

t res

ult (

P/N

)

Targ

et p

opul

ation

Cat

egor

y w

rite

cod

e H

IV T

est r

esul

ts re

ceiv

ed

with

pos

t tes

t cou

nsel

ing(

√)H

IV p

ositi

ves

linke

d to

PM

TCT

(√)

Know

n H

IV p

ositi

ves

(t

rans

ferr

ed fr

om A

RT)(

√)

HIV

Tes

t acc

epte

d (√

)

Part

ner

HIV

Tes

t res

ult (

P/N

)

Targ

et p

opul

ation

Cat

egor

y co

de

HIV

pos

itive

s Pa

rtne

r lin

ked

to A

RT

Dan

ger

sign

s(√)

Mat

erna

l Nut

ritio

n( √

)

Earl

y Ch

ild D

evel

opm

ent

(ECC

D) (

√)Br

east

feed

ing/

Infa

nt fe

edin

g

(√)

Fam

ily p

lann

ing(

√)

(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35)

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

* If mother comes from other woreda write the woreda and kebele

Targeted population category (Colm. 22) A. Female Commercial Sex workers B. Long distance drivers C. Mobile workers/daily laborers D. Prisoners E. OVC/Children of PLHIV F. Other MARPS G.General Population

Antenatal Care Register


Health Centre /Clinic/Hospital Delivery Register

Identification

1 S.N Sequential serial number in registration book; to be entered in client’s registration cared for later identification in the register

2 MRN Medical Record Number( MRN) unique individual identifier used in medical information folder, for HC and hospital

3 Name Write the name of the mother who deliver4 Age Write age of the mother in years 5 Kebele Write Kebele where the mother comes fromLabor and maternal outcomeMode of Delivery6 Delivery Date and time Write delivery date and time of the client as (E.C.). DD/MM/YY- 00:007 Partograph Used Write “Y” if maternal condition, Fetal condition & Progress of labor monitored, If not all write “N”8 SVD ( spontaneous vaginal delivery ) Tick ( √) for spontaneous vaginal delivery 9 Caesarean Section (C/S) Tick ( √) if the delivery is caesarean section10 Forceps /Vacuum Assisted (√) Tick ( √) if the delivery is Forceps /Vacuum Assisted 11 Episiotomy (√) Tick ( √) if the delivery supported by episiotomy 12 Other (√) Tick ( √) if the delivery is by other (Assisted breach, Detractive, etc)Active management of 3rd stage labour

13 Uterotonic Drugs Given within one minute after delivery (Write code) Write codes listed in raw 23 (Write 1=Oxytocin, 2=Misoprostol, 3= Ergometrine 4= Other

14 Controlled cord traction (CCT) Tick ( √) for CCT performedMaternal status 15 Stable Tick( √) if the mother is stable 16 Unstable/deteriorated and referred to the

next facility (√) Tick ( √) if the mother maternal status is unstable /deteriorated and referred to other facility

17 Died Tick( √) if the mother died

18 Cause of maternal death

1 Hemorrhage2 PE/Eclampsia3 Obstructed Labore 4 Sepsis5 Anemia6 Others

Obstetric complications during intra-partum19 Pre-eclampsia (√) Tick ( √) if there is pre- eclampsia20 Eclampsia (√) Tick( √) if there is eclampsia 21 APH(√) Tick ( √) if there is Antepartum hemorrhage (APH)22 PPH(√) Tick ( √) if there is Post Partum Hemorrahge (PPH)23 Other obstetric complications (√) Tick ( √) if other obstetric complications (such as Obstructed labor, Sepsis, etc) occurred 24 Referred (√) Tick ( √) if the client is referred New born birth outcome 25 Alive (√) Tick ( √) if the newborn is live birth 26 APGAR score 1’/5’ Write the APGAR score of the newborn at the first and fifth minute of birth (1st minute /5th minute)27 Sex (M/F) Enter M for Male and F for female28 Weight in gram Write the weight of the newborn in gram29 Still birth (√) Put 1 if still birth is fresh and 2 if it is macerated

30 Live birth, died after arrival or delivery in facility(√)

Tick (√) if the live birth died after arrival or delivery in facility. these newborn death should be reported as ‘new born death within 24 hours )

Preventive services: Newborn 31 MRN (Newborn’s) Enter Newborn’s Medical Record Number(MRN) 32 Vitamin K (√) Tick( √) if the newborn received vitamin K33 TTC eye ointment (√) Tick( √) if TTC is applied for the newborn 34 Chlorhexidine (√) Tick( √) if Chlorhexidane is applied for the newborn 35 Vaccinated at birth for (Write code) Write code 1 for BCG, 2 for OPV 0, 3 for HBV. NB: You can use more than one codePreventive services : maternal HIV+ care and follow-up36 HIV testing accepted (√) Tick ( √) if the mother accepts testing for HIV 37 HIV retesting accepted (√) Tick ( √) if the mother have already tested and know her status negative but risk for HIV38 HIV test status ( P/ N) Write P in red pen if the test result is positive, write N in normal color if the result is negative.

39 Known HIV positives (linked from ART) (√) Tick ( √) if the women is known HIV positives and linked from ART

INSTRUCTION FOR DELIVERY CARE REGISTER

The register is kept in delivery room (HC/Clinic/Hospital) completed by delivery care provider.

Location information to be completed at front of the register:







Write the code target population category listed below the register. an individual needs to be assigned only in one category that best describe him/her.

A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPS


41HIV positive delivery link to PMTCT

( code:1 = same facility ,2= other facility)Write 1 if the mother linked to PMTCT in same facility and write 2, if mother linked to other facility PMTCT.

42 Counseled on feeding options (√) Tick ( √) if the mother counseled for feeding options 43 Mother’s ART Regimen write code Write mother’s ART regimen code44 Newborn AZT + NVP (for 6 wks/12 wks) Tick ( √) Newborn AZT + NVP for 6 wks & NVP only the next 6 wksPartner HIV testing 45 Partner HIV testing accepted ( √) Tick ( √) if the partner/husband accepts testing for HIV 46 Partner HIV test result ( P/ N) Write P in red pen if the test result is positive, write N in normal color if the result is negative.47 HIV Positive partner Linked to ART Tick (√) if the partner is positive and linked to ART.48 Target population Category Write code see column.38 for codingIPPFP ( Immediate Post-Partum family planning )

49 New acceptor (√) Tick (√) if client is new acceptor at the time of registration. A new acceptor is someone who has not received a contraceptive method from a recognized Provider before registration.

50 Repeat acceptor (√)Tick (√) if client is repeat acceptor at the time of registration. A repeat acceptor is someone who is not a new acceptor; in other words, a repeat acceptor has received a contraceptive method from a recognized Provide before registration.

51Type of immediate PPFP methods received

(0-48hrs)

Write the type of contraceptive provided

POP=Progestin only pill

Imp=Implant

IUCD=Intrautrine device

TL=Tubaligation

Oth=Other Problem identified : Newborn 52 Prematurity ( √) Tick( √) if the newborn is premature 53 Sepsis/ (VSD) ( √) Tick( √) if the new born has sepsis or very sever disease (VSD)54 Respiratory distress/asphyxia ( √) Tick ( √) if the newborn has respiratory distress or asphyxia55 Low birth weight ( √) Tick( √) if the newborn is low birth weight (LBW)56 Congenital malformation ( √) Tick( √) if the newborn has Congenital malformation 57 Other (specify ) Tick ( √) if the newborn has other problems

58 Breast feeding initiated time write codeWrite the code for breast feeding option 1.<1hr , 2.1-2hr , 3.>3hrs, 4.Not at all

5.Other milk Treatment given and out come59 Oxygen resuscitated ( √) Tick ( √) if the newborn treated with oxygen/resuscitation 60 Resuscitated and survived (√) Tick( √) if the newborn is resuscitated and survived61 Died(√) Tick( √) if the newborn is died62 Age at death Write the age of the newborn in days and hours 63 Cause of death Write code for new born cause of death as 1.Prematurity 2.Infection 3.Asphexiya 5.Other

64 If alive, Birth notification given for the mother ( √) Tick if the mother given birth notification

65 Managed by Write the name and signature of the care provider 66 Remark Write any appointment or other concerns not addressed in this registry book

NB** If twin or triple deliver occurs use consecutive rows for each newborn

Delivery Services Preventive ServicesIdentification Labor and Maternal Outcome

Obstetric Complications Newborn birth Outcome** Newborn Maternal HIV+ care and followupPersonal information

Delivery date and time

(DD/MM/YY - 00:00)

Part

ogra

ph U

sed

(Y/N

)

Mode of Delivery Active management of 3rd stage labour Maternal Condition

S.N MRN Name of the mother Age

Kebe

le

SVD

(√)

Caes

area

n se

ction

(C/S

) (√)

Forc

eps /

Vac

uum

Ass

iste

d (√

)

Epis

ioto

my

(√)

Oth

er p

roce

dure

s (√)

Ute

roto

nic

Drug

s Giv

en w

ithin

one

min

ute

after

del

iver

y (W

rite

code

)

Cont

rolle

d co

rd tr

actio

n (C

CT)

Stab

le (√

)

Uns

tabl

e /

dete

riora

ted

and

refe

rred

to

the

next

faci

lity

(√)

Died

(√)

Caus

e of

Dea

th (W

rite

Code

)

Pre-

ecla

mps

ia (√

)

Ecla

mps

ia (√

)

APH

(√)

PPH(

√)

Oth

er O

bste

tric

Com

plic

ation

s (√)

Refe

rred

(√)

Aliv

e (√

)

APG

AR S

core

1’ /

5’

Sex

(M/F

)

Wei

ght i

n gr

ams

Still

birt

h (1

= Fr

esh,

2=

Mac

cera

ted)

Live

birt

h, d

ied

after

arr

ival

or d

eliv

ery

in

faci

lity

(√)

MRN (New

born’s)

Vita

min

K (√

)

TTC

eye

oien

tmen

t (√)

Chlo

rhex

idin

e co

rd c

are

(√)

Vacc

inat

ed a

t birt

h fo

r (W

rite

code

)

HIV

Testi

ng a

ccep

ted

(√)

HIV

re-t

estin

g ac

cept

ed (√

)

HIV

Test

resu

lts (P

,N)

Know

n HI

V po

sitiv

es

(link

ed fr

om A

RT)(√

)

Targ

et p

opul

ation

Cat

egor

y w

rite

code

HIV

posi

tive

deliv

ery

link

to P

MTC

T (

code

:1 =

sam

e fa

cilit

y ,2

= ot

her f

acili

ty)

Coun

sele

d on

feed

ing

optio

ns(√

)

Mot

her’s

ART

Reg

imin

(writ

e th

e co

de)

New

bor

n AZ

T +

NVP

(for

6 w

ks/1

2 w

ks)

(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44)

Cont DeliveryCount

C/S

Count Maternal

deathsCount PPH

count Live

births Total Weighed

Total Still

birth

count Newborn

deathscount

Chlorhexidine

<=2000 Fresh

b/n 2000 & 2500 M

ac-

cera

ted

Delivery Register

NB** If twin or triple deliver occurs use consecutive rows for each newborn

Cause of maternal death Col(18)1 Hemorhage, 4 Sepsis2 PE/Eclampsia 5 Aneamia3 Obstructed Labore 6 Others

Write ART regimine code on col.(43)1c = AZT-3TC-NVP1d = AZT-3TC-EFV1e = TDF-3TC-EFV1f = TDF-FTC-NVP1J = TDF-3TC-DTG 1g = Others, specify

Uterotonic Drugs Given code Col(13)1 = Oxytocin 2 = Misoprostol 3 = Ergometrine 4 = Other

Vaccinated at birth col(35)1 .BCG 2 .OPV 0 3 . HBV NB: You can use morethan one code

Targeted population category (40)A. Female Commercial Sex workers B. Long distance drivers C. Mobile workers/daily laborers D. Prisoners E. OVC/Children of PLHIVF. Other MARPS G.General Population

Delivery RegisterPartner testing IPPFP* Newborn

If al

ive,

Birt

h no

tifica

tion

give

n fo

r mot

her (

√)

Managed by Remark

Part

ner H

IV T

estin

g ac

cept

ed (√

)

Part

ner H

IV T

est r

esul

ts (P

/N)

HIV

posi

tives

Par

tner

link

ed to

ART

(√)

Targ

et p

opul

ation

Cat

egor

y

New

acc

epto

r (√)

Repe

at a

ccep

tor(

√)

IPPF

P m

etho

ds re

ceiv

ed (

0-48

hrs)

use

abb

reva

tion

Problem identified

Brea

st fe

edin

g in

itiat

ed ti

me

writ

e co

de

Treatment and outcome

Age

at d

eath

(pos

tnat

al a

ge)

Cause of death 1.Prematurity

2.Infection 3.Asphexiya

5.Other

Prem

atur

ity (√

)

Seps

is/

VSD(

√)

Resp

irato

ry d

istr

esse

/asp

hyxi

a (√

)

Low

birt

h W

eigh

t (√)

Cong

enita

l Mal

form

ation

(√)

Oth

er (W

rite

Code

)

Oxy

gen/

Res

usci

tatio

n(√)

Resu

scita

ted

and

surv

ived

(√)

Died

(√)

(45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65) (66)

Count sepsis casesCount #

resuscitatedCount # Resusci-tated & survive

count # of deaths within

0-24hrs

count # of deaths within

1-7 days

Use FP tally Sheet to capture Age and Method disaggregation MOH V1 2021

Use Abbrevation For col. 51POP=Progestin only pillImp=ImplantIUCD=Intrautrine deviceTL=TubaligationOth=Other

Breast feeding initiated time code col (58)1.<1hr 4.Not at all 2. 1-2hr 5.Other milk3.>3hrs

* To avoide duplication IPPFP should be registered only if service is provided in the unit


Health Centre /Clinic/Hospital PNC Register

The register is kept in PNC room (HC/Clinic/Hospital) completed by postnatal care provider Location information to be completed at front of the registry



Name of Health Facility Write the name of the health facility.

Register begin date Enter the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register end date Enter the date of the last entry in the register, written as (EC) Day / Month Year(DD/MM/YY)

SN Datum Comments

Identification information: Personnel 1 S.N Sequential serial number in registration book; to be entered on client’s registration card for later identification in the register 2 Name Write the Name of the Mother 3 MRN Unique individual identifier for mother used on medical Information folder, for HC and hospital.4 Age Write age of the mother in years 5 Woreda / Kebele Write Woreda in upper row and Kebele in the lower row6 Infant’s date of birth Infant’s date of birth written as (DD/MM/YY)

7 Place of Delivery write codewrite code place of delivery 1=Same Facility 2=Other Facility3=Home

8 MRN (Infant’s )Information folder, for HC and hospital.Unique individual identifier for infant used on medical

9 Sex (M/F) Enter M for male or F for female

PNC visits:

10 Visit Time (period)

Visit time: • 24 hrs = PNC visit period for those mothers stay 24 hours after delivery. • 25-48 hrs = For those mothers who came for PNC service within 25-48 hrs after delivery. • 49-72 hrs = For those mothers who came for PNC service within 49-72 hrs after delivery• 73 hrs -7days = For those mothers who came for PNC service within 73 hrs -7days after delivery• 8-42days = For those mothers who came for PNC service within 25-48 hrs after delivery

11 Date of visit (DD/MM/YY) Write date of the visit in (DD/MM/YY) in Ethiopia calendar

Assessment : Maternal

12Maternal Health Condition writ code

Write code 1.Normal 2.Complicated and managed 3.Complicated and referred4. Died

Maternal Complication13 PPH (√) Tick(√) if the mother developed PPH

14Other Obstetric Complications

Other Obstetric Complications (Write code: PE, E, SEP, OTH)

HIV assessment

15 HIV Test accepted(√) Tick (√) if the women accepted HIV Test.

16 HIV re-testing accepted (√) Tick(√) if HIV re-testing is accepted

17 HIV test result (P or N) Write P for HIV positive result and N for HIV negative results

18Targeted population category write code

Fill column 15 selecting from the list of target population category listed, an individual needs to be assigned only in one category that best describe him/her.


I. General population19

HIV Positive Linked to ART(√)

Tick (√) if the woman is positive and linked to ART.

20Known HIV positives (transferred from ART) (√)

Tick if the mother is known for HIV positive referred from ART

Partner testing

21 HIV Testing accepted Tick (√) if HIV test offered

22 HIV Test results (P or N) Write P for HIV positive, N for negative result and I for indeterminate result

23Targeted population category Use the above category code

24HIV Positive partner Linked to ART

Tick (√) if the partner is positive and linked to ART.

Counseling on25 Danger signs(√) Tick (√) if Counseling on Danger signs given

26 Breast feeding/nutrition(√) Tick (√) if Counseling on Breast feeding/Nutrition is given

27Newborn care (including cord care) (√)

Tick (√) if Counseling on Newborn care and cord care given

28 Family Planning(√) Tick (√) if Counseling on Family Planning given

29 EPI(√) Tick (√) if Counseling on EPI given

30Early Childhood Development(√)

Tick (√) if Counseling on Early Childhood development / Care for Child Development

Assessment infant/ newborn31 Weight in grams Write weight of newborn in gram

INSTRUCTIONS FOR POSTNATAL CARE REGISTRATION

32 Breastfeeding Tick (√)if newborn is breastfeeding

33 Problem identified

Write code if more than one problem was identified write all codes separate with comma like (1,5,7…..) (write code) 1.Normal2.prematurity 3.sepsis/VSD4. respiratory distress5.perinatal asphyxia6.LBW7.Congenital malformation8.Abscence of reflex. 9.Jaundice. 10. HC <33cm. 11.Other (specify)

34 Treatment Given

Write code if more than one treatment was given identified write all codes separate with comma like (1,5,7…..)Treatment** given (write code)1.Oxygen resustation2.KMC3.Antibiotic4.Chlorhexidene5.Blood transfusion6.Others

35 Treatment OutcomeTreatment Outcome (Write code):1. Improved, 2.No change, 3. Died , 4.Referal 5.Unknown , 6.Resuscitated and survived

36 Age at death Write age of death in days

37 Cause of Death Write codeWrite code cause of death 1.Prematurity, 2.Infection3.Asphexiya, 4.Other

IPPFP

38 New acceptor (√) Tick (√) if client is new acceptor at the time of registration. A new acceptor is someone who has not received a contraceptive method from a recognized Provider before registration.

39 Repeat acceptor (√) Tick (√) if client is repeat acceptor at the time of registration. A repeat acceptor is someone who is not a new acceptor; in other words, a repeat acceptor has received a contraceptive method from a recognized Provide before registration.

40Type of immediate PPFP methods received( 0-48hrs)

Contraceptive method provided (record modern methods only) Abbreviate type as follows:POP=Progestin only pillImp=ImplantIUCD=Intrautrine deviceTL=TubaligationOth=Other

41 Managed by Write name of care provider that give service for specific visit

42 Remark Enter Any Remark

Identification PNC Visits

Mat

erna

l Hea

lth C

ondi

tion

wri

t cod

e

Maternal Complication

HIV Assessment

Know

n H

IV p

ositi

ves

(tra

nsfe

rred

from

ART

) (√

)

Partner testing Counseled on Newborn IPPFP

Managed by

Rem

ark

Personal information

Infa

nt’s

Dat

e of

bir

th(D

D/M

M/Y

Y)

Plac

e of

Del

iver

y (w

rite

cod

e)

MRN

(Infant’s)

Sex

(M/F

)

Visit Time (Period)

Date of visit

(DD/MM/YY) PP

H (

√)

Oth

er O

bste

tric

Com

plic

ation

s (W

rite

co

de: P

E, E

, SEP

, OTH

)

HIV

testi

ng a

ccep

ted

(√)

HIV

re-t

estin

g ac

cept

ed (√

)

HIV

test

resu

lt (P

/N)

Targ

et p

opul

ation

Cat

egor

y w

rite

cod

e

HIV

pos

itive

s lin

ked

to A

RT(√

)

HIV

Tes

ting

acce

pted

(√)

HIV

Tes

t res

ults

(P/N

)

Targ

et p

opul

ation

Cat

egor

y w

rite

cod

e

HIV

pos

itive

s Pa

rtne

r lin

ked

to A

RT(√

)

Dan

ger

sign

s(√)

Brea

st fe

edin

g/nu

triti

on(√

)

New

born

car

e (in

ludi

ng c

ord

care

) (√)

Fam

ily P

lann

ing(

√)

EPI(√

)

Earl

y Ch

ildho

od D

evel

opm

ent (

ECD

) (√)

Wei

ght i

n gr

am

Brea

st fe

edin

g(√)

Prob

lem

** id

entifi

ed (w

rite

cod

e) Treat-

ment** given (write code)

1.Oxygen resustation

2.KMC 3.Antibi-

otic 4.Blood

transfusion 5.Others

Trea

tmen

t Out

com

e (W

rite

cod

e)

Age

at d

eath

Cause of death

Write code 1.Prematu-

rity 2.Infection 3.Asphexiya

4.Other

New

acc

epto

r (√

)

Repe

at a

ccep

tor(

√)

type

of i

mm

edia

te P

PFP

met

hods

re-

ceiv

ed( 0

-48h

rs)

***

S.N Name MRN AgeWoreda/ Kebele

(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42)

24 hrs

25-48 hrs

49-72 hrs

73 hrs -7 days

8 - 42 days

24 hrs

25-48 hrs

49-72 hrs

73 hrs -7 days

8 - 42 days

24 hrs

25-48 hrs

49-72 hrs

73 hrs -7 days

8 - 42 days

24 hrs

25-48 hrs

49-72 hrs

73 hrs -7 days

8 - 42 days

24 hr (1 days)Maternal death

Count PPH

Count HIV tested

Count # of newborn Resuscitated & survive

25-48 hrs (1-2 days)

Count # of deaths with-in 0-24hrs

49-72 hrs (2-3 days Count # of deaths within

1-7 days

73 hrs -7 days (4-7days)

Count # of deaths within 7-28 days

Use FP tally Sheet to capture Age and Method disaggregation***In order to avoide duplication IPPFP should be registered only if service is provided in the unit

Use Abbrevation For col. 40 POP=Progestin only pill Imp=Implant IUCD=Intrautrine device TL=Tubaligation Oth=Other

PNC Register

Place of Deliverycode :col(7)

1=Same Facility2=Other Facility3=Home

Targeted population category (18) A. Female Commercial Sex workers B. Long distance drivers C. Mobile workers/daily laborers D. Prisoners E. OVC/Children of PLHIVF. Other MARPS G.General Population

Maternal Health Condition code :col(12)1.Normal 2.Complicated and managed 3.Complicated and referred4. Died

1.Normal 2.Complicated andmanaged NB **Write code if more than one problem was identified/Treatment given write all codes separate with comma like (1,4,6…..)NB **Write code if more than one problem was identified/Treatment given write all codes separate with comma like (1,4,6…..)

Problem** identified (write code): Col.(33)1.Normal 2.prematurity 3.sepsis/VSD 4. respiratory distress5.perinatal asphyxia 6.LBW7.Congenital malformation8.Abscence of reflex. 9.Jaundice. 10. HC <33cm. 11.Other (specify)

Treatment Out come, Code for Col.351.Improved2.No change 3. Died 4. Referal 5. Unknown6. Resuscitated and survived


Health Centre /Clinic/Hospital PMTCT Register

Col.No Data Element Description

1 S. N. Sequential serial number in registration book, beginning with 1 for the first client in the cohort.

2 Mother’s name Write name of the mother

3 MRN Write Unique individual identifier for mother used on medical Information folder, for HC and hospital.

4 ART unique ID number

Record the existing Unique ART number or assign one during initiation. A unique ART number should be assigned to clients initiated on ART at MNCH clinic. This includes: region number / facility

type code / specific facility code / client assigned number.

Region number: the following code numbers are used:

Tigray:- 01 SNNPR:- 07

Afar:- 02 Gambella :- 12

Amhara:- 03 Harar :- 13

Oromia:- 04 Addis Ababa :- 14

Somali:- 05 Dire Dawa :- 15

Benishangul Gummuz :-06 Sidama :- 16

South West Ethiopia:- 17

Facility type code: Hospital =08

Health Center = 09

Each HC / hospital in each region is coded with three digits starting from 001. These specific facility codes are assumed to be given by regions together with federal, which means it is pre coded and

given to each facility centrally.

Patient assigned number: A 5 digit number unique within the facility; the first pregnant woman to start ART in the clinic will be given 00001.

Example Unique ART No. 01/08/001/00001

5 Age Age of the woman in years, Document the clients age in the column,

6 Booking Date Booking date is the first date for Maternal enrollment in PMTCT. If the mother starts ART in the PMTCT clinic in the same day, this date will be the same with ART start date. But for mothers who

had already started ART, the booking date will be entered and as a result the date will be different from ART initiated date

7Newly diagnosed & started on ART

write code (1=ANC; 2=L&D; 3=post partum)

Write “1” for the women who are diagnosed and started on ART during ANC for the first time.

Write “2” for the women who are diagnosed and started on ART during at L&D for the first time.

Write “3” for the women who are diagnosed and started on ART during PNC for the first time.

8Known HIV + write code (1=On ART at entry;

2=Not on ART)

Write “1” for woman who was started on ART before PMTCT entry.

Write “2” for known HIV + women was not started ART before PMTCT entry .

9 LNMP Write the date (DD/MM/YY) of the last normal menstrual period.

10 EDD Write the Expected date (DD/MM/YY) of delivery.

11 Gestational age (GA) in weeks Write the gestational age (GA) in weeks.

12 Ferrous Sulfate/Folic Acid Provided(Y/N)Write “Y” if ferrous sulphate / folic acid is provided

Write “N” if ferrous sulphate / folic acid is not provided

INSTRUCTIONS FOR INTEGRATED MNCH/PMTCT REGISTERRegion Write the region where the facility is locatedZone/Sub-City /Woreda Write the Zone/Sub-City /Woreda where the facility is located.Name of Health Facility Write the name of the health facility

Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Write the date of the last entry in the register, written as (EC) Day / Month Year(DD/MM/YY)

13 Syphilis test result (R/NR/ND)

Write “R” if the syphilis test result is Reactive,

Write “ N” if the syphilis test result is not Reactive

Write “ND” if syphilis test is not done.

14

Selected Infant Feeding option (EBF, ERF, MF) Write “EBF” if the mother selects exclusive breast feeding.

Write “ERF” if the mother selects exclusive replacement feeding.

Write “MF” if the mother selects mixed feeding.

15 Date of delivery Write the date the mother gave birth E.C. (DD/MM/YY)

16 Sex of Infant ( M/F ) Write “ M” if the Infant is Male or Write “F” if the Infant is Female

17 Place of Delivery (write code)Write code for Place of Delivery

1= same facility, 2= another health facility 3= home delivery.

18 Delivery Outcome (LB,SB) Write “LB” if delivery outcome is Live Birth or Write “SB” if delivery outcome is Still birth.

19 ART Taken During Labor (Y/N) Write “Y” if the woman took ART during delivery or “ N” if the women didn’t take ART during delivery

20

Infant Received ARV Prophylaxis (AZT + NVP

for the 1st 6 weeks and NVP only for the next 6

weeks with a total of 12 weeks) (Y/N)

Write “Y” Infant Received ARV Prophylaxis (AZT + NVP for the 1st 6 weeks and NVP only for the next 6 weeks with a total of 12 weeks) , otherwise write “N” if not given

21 Family Planning Counseled(Y/N) Write “Y” if the mother is counseled on family planning or “N” if the mother is not counseled on family planning.

22 New acceptor (√) Tick (√) if client is new acceptor at the time of registration. A new acceptor is someone who has not received a contraceptive method from a recognized Provider before registration.*

23Repeat acceptor (√) Tick (√) if client is repeat acceptor at the time of registration.

A repeat acceptor is someone who is not a new acceptor; in other words, a repeat acceptor has received a contraceptive method from a recognized Provide before registration.

24 Contraceptive provided (write abbreviation) Write abbreviation of modern contraceptive methods a client chose. See the abbreviation on the register.

25 HIV testing accepted ( √) Tick ( √) if the partner/husband accepts testing for HIV

26 Partner tested (P/N/ND) Write “P” if test result is positive, Write “N” if the test result is negative, and Write “ND” if partner test is not done.

27

Partner Target population Category write code Write the selected from the following list of target population category. An individual should be assigned to only one category that best describes him/her.

A= Female Commercial Sex workers , B= Long distance drivers, C= Mobile/Daily Laborers, D= Prisoners, E= OVC, F= Children of PLHIV, G= Partners of PLHIV,

H= Other MARPS, I= General population

28 HIV Positive partner Linked to ART Tick (√) if the partner is positive and linked to ART.

29 TB symptom screening (P/N/ND) Write the mother’s TB symptom screening result as “P” for Positive, “N” for Negative and “ND” for test not done

30 Date INH prophylaxis started Write the date as E.C(DD/MM/YY) INH prophylaxis is initiated.

31 Date TB Rx started/Unit TB Number Write the date as E.C(DD/MM/YY) TB Rx is initiated on the upper row and unit TB Number in lower row.

32 Initial CD4 count(Value/ND)Write initial mother’s CD4 count value as a baseline for newly enrolled mothers in PMTCT after initiating ART as soon as possible. For those mothers who are already on ART during enrollment, the

most recent CD4 count value has to be documented or write ND if CD4 count is not done

33 WHO Clinical Stage Write mother’s WHO clinical stage.

34 Maternal CPT started (Y/N) Write “Y” if mother started CPT prophylaxis or Write “N” if mother didn’t start CPT prophylaxis.

35 Date ART initiated Write ART start date on which ART was started and could be the same as booking date for those clients newly started ART.

36 Initial ART Regimen (write Code) Write the code for the regimen that patient has started. This is found at the bottom of the ART register.

37 Infant’s MRN Write the medical record number of the HIV exposed infant

38 Date of HEI enrollment to PMTCT Write date of the HIV Exposed Infant (HEI) enrolled in PMTCT cohort

39 Infant Received ARV prophylaxis (DD/MM/YY) Write the date ARV prophylaxis was initiated as ( DD/MM/YY)

40Infant feeding practice within the first 6 months

(EBF/ ERF/ MF)

Write “EBF” if exclusive breastfeeding; “ERF” if replacement feeding; “MF” if mixed feeding. Provider should refer the patient follow up card, ask the mother “what, how did she feed her baby ev-

ery time she comes for follow up (Complete this at 6th month of infant age) to document the status

41 Age in wks Started CPT Write age in weeks when the infant initiated Cotrimoxazole prophylaxis.

42 Age in weeks DNA/PCR test done (WKs) Write age in weeks DNA/PCR test done.

43 Result of DNA/ PCR(P/N) Write “P” if positive or “N” if negative.

44 Rapid HIV-AB test result(P/N) Write “P” if HIV-AB test result is positive or “N” if HIV-AB test result is negative

45Counseled on Care for Child Development/CCD

(Y/N)Write ‘y’ it counseling is given to the client on Child Development, otherwise write ‘N’

46 Counseled on Nutrition (Y/N) Write ‘y’ it counseling is given to the client on Nutrition, otherwise write ‘N’

47 Remarks Write important patient related issues not incorporated in the list of data elements.

Right Side of the page (48-89)

Month “

0” in the

Right

Page

Month “0” in the Right Page is the initial month and year (MM/YY) that the mothers are enrolled in PMTCT service. This is the shared event for maternal cohort monitoring and analysis of the maternal outcome such as retention and viral load

suppression a well as others.

Maternal enrolment to PMTCT cohort (MM ,YY) is also the shared event for HEI PMTCT Cohort

TO,TI

,LTF

Write transfer out (TO), transfer in (TI) and lost to follow up (LTF) in the column and row (cell) corresponding to each client followed in the cohort when the situation takes place. –Fill out a formal TO format for clients who is transferring to

other PMTCT and ART sites.

Write TI for clients transferred out from other PMTCT sites and who came with formal TO.

N.B.

Clients coming from ART clinics are not considered as TI. These clients are considered as newly enrolled to PMTCT cohort for the purpose of the current pregnancy.

Write LTF in the cell for mother miss their appointment for more than two months.

Cohort

follow

up for

the Ma-

ternal

and HEI

PMTCT

cohort

Fill the status of mother and infant in each visit using the codes mentioned and write their sums every months at the bottom of each column

Write maternal viral load result at 3 months of ART initiation for newly started ART then put the result every 6 months in the lower row.

If viral load is <1,000 copies per ml, write un detectable ; otherwise write detectable or >1000 copies /ml.

Arrows

For data elements related with “Maternal Status”, • Put the total number of retained /alive & On ART

• Put the total number of “LTF”

• Put the total number of “TO”

• Put the total number of mothers with detectable Viral load >1000 copies

• Put the total number of mothers Malnourished

• Put the number of deaths.

For data elements related with “Infant status”, • Put the total number of infants Still on BF /Exposed

• Put the total number of positive infants “LTF”

• Put the total number of Discharged negative infants

• Put the total number of positive infants

• Put the total number of “TO”

• Put the number of infant died.

PMTCT Register for Health Centre/ HospitalRegistration

New

ly d

iagn

osed

& st

arte

d on

ART

w

rite

code

(1=A

NC;

2=L

&D;

3=p

ost p

artu

m)

Know

n HI

V +

writ

e co

de (

1=O

n AR

T at

ent

ry;

2=N

ot o

n AR

T)

ANC Delivery

Infa

nt R

ecei

ved

ARV

Prop

hyla

xis (

AZT

+ N

VP

for t

he 1

st 6

wee

ks) &

(NVP

onl

y fo

r the

nex

t 6

wee

ks) t

otal

12

wee

ks (

Y/N

)

Fam

ily P

lann

ing

Coun

sele

d(Y/

N)

New

acc

epto

r (√)

Repe

at a

ccep

tor(

√)

Cont

race

ptive

pro

vide

d( U

se a

bbre

viati

on ) HIV Care to be Filled when applicable HIV Exposed Infant Counseled on

Rem

ark

S.N

Identification

LNM

P

EDD

Ges

tatio

nal A

ge in

wee

ks (G

A)

Ferr

ous S

ulfa

te/F

olic

Aci

d Pr

ovid

ed(Y

/N)

Syph

ilis t

est r

esul

t (R/

NR/

ND)

Sele

cted

Infa

nt F

eedi

ng o

ption

(E

BF,

ERF,M

F)

Date

of D

eliv

ery

Sex

of In

fant

( M

/F)

Plac

e of

del

iver

y w

rite

code

(1=S

ame

Faci

lity,

2=O

ther

Fac

ility

,3=H

ome)

Deliv

ery

outc

omes

(LB,

SB)

ART

Take

n Du

ring

Lab

or (Y

/N )

HIV

Testi

ng a

ccep

ted

(√)

Part

ner t

este

d (P

/N/N

D)

Targ

et p

opul

ation

Cat

egor

y (w

rite

code

)

HIV

posi

tives

Par

tner

link

ed to

ART

TB sy

mpt

om sc

reen

ing

(P/N

/ND)

Date

INH

prop

hyla

xis/

TB

Rx st

arte

d

Date

TB

trea

tmen

t Sta

rted

/

unit

TB N

umbe

r

Initi

al C

D4 te

st(V

alue

or N

D)

WHO

Clin

ical

Sta

ge

Mat

erna

l CPT

star

ted

(Y/N

)

Dat

e AR

T in

itiat

ed

Initi

al A

RT R

egim

en( w

rite

Cod

e)

Infa

nt’s

MRN

Date

of H

EI e

nrol

lmen

t to

PMTC

T

Infa

nt R

ecei

ved

ARV

Prop

hyla

xis (

DD/

MM

/YY)

Infa

nt fe

edin

g pr

actic

e w

ithin

the

first

6

mon

ths (

EBF/

ERF

/ M

F)

Age

in W

ks S

tart

ed C

PT

Age

in W

eeks

DN

A/PC

R te

st d

one

(Wks

)

Resu

lt of

DN

A/ P

CR(P

/N)

Rapi

d HI

V-AB

test

resu

lt at

/ w

ith in

18

m

onth

s of a

ge (

P/N

)

Early

Chi

ldho

od D

evel

opm

ent/

ECD

(Y/N

)

Nut

rition

(Y/N

)

Mother’s Name MRN ART

unique ID Number

Age

Book

ing

Date

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

Partner Tested

Partner +ve

Cohort : Month _______________ Year ________________ (MM/YY for Maternal Enrollment In PMTCT Cohort)

Use Abbrevation For col. 24Con=CondomOC=Oral contraceptiveInj=InjectabileImp=Implant(Implanon,Jadille,Sinoplant)IUCD=Intrautrine deviceOth=Others

Key ART regimen Code (36)1c = AZT-3TC-NVP1d = AZT-3TC-EFV1e = TDF-3TC-EFV1f = TDF-FTC-NVP1J = TDF-3TC-DTG Others, specify

Targeted population category (27)A. Female Commercial Sex workers B. Long distance drivers C. Mobile workers/daily laborers D. Prisoners E. OVC/Children of PLHIVF. Other MARPS G.General Population

PMTCT Register for Health Centre/ Hospital

Client RXs

Months 0-6 Months 7-12 Months 13-24 Months 25-30

Month “0” 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 26 27 28 29

30

Regi-men

Viral load

Regi-men MUAC

CD4

Regi-men MUAC

CD4

Regi-men MUAC

CD4

Regi-men MUAC

CD4

Regi-men MUAC

CD4

Viral load

Viral Load

Viral Load

Viral Load

Viral Load

48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89

mother 1J Other Specify

Infant

AZT /NVP

CPT

mother 1J/Other Specify

Infant

AZT /NVP

CPT


Infant

AZT /NVP

CPT


Infant

AZT /NVP

CPT


Infant

AZT /NVP

CPT

Maternal PMTCT cohort Outcomes

# Retained /Alive & On ART

# LTF for Lost to follow up of appointment ;

# TO for Transferred Out;

# Viral load >1000 copy

# Malnourished /< Standad BMI

# D for Known Dead

HEI PMTCT Outcomes

# Still on BF /Exposed/on CPT

# LTF for Lost to Follow up of appointment

# DN for Discharged negative infants after Ab. test result at 18 months of age

# P for Positive

#TO for Transferred Out;

# Malnourished / Underweight for age

# D for Known Dead

Cohort register (Right) Year:_____________ Page 2


Health Centre /Clinic/Hospital Comprehensive Abortion Care

Services Register

The abortion care register is completed from women’s card by care provider

Location information to be completed at front of the register:



Name of Health Facility Write the name of the health facility where the PNC was provided.


Register end date Enter the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)

S.n Datum Comments

1 S.N Sequential serial number in registration book;to enter on client registration book for later identification in register

2 Date Date of service provision for comprehensive abortion care service in dd/mm/yy

3 MRN Unique individual identifier used on medical information folder, for health center and hospital

4 Age Write age in years

5 Gestational age (wks) Write the gestational age of the pregnancy calculated in weeks

6 Gravida Write the number of pregnancies

7 Para Write the number of births

8 Number of previous abortions Write the number of abortions the women have had

9 Safe abortion (√) Tick if the safe abortion service is given

10 Post abortion care (√) Tick if the post abortion care is given

11 Diagnosis/ Reason for safe/post abortion care Write the corresponding codes for reasons of abortion from the footnote of the register

Types of uterine evacuation

12 MVA (√) Tick (√)if the procedure is manual vacume aspiration

13 E &C(√) Tick(√) if the procedure is done by E&C

14 MA(√) Tick(√) if the procedure is done by MA

15 D&E(√) Tick(√) if the procedure is given by D&E

16 Other specify Writ it if the abortion service is given by other methods

Managed as

17 Outpatient (√) Tick (√)if the client is managed at an out patient

18 In patient (√) Tick (√)if the client is managed as in patient

19 Referred (√) Tick(√) if client is referred

20Drugs provided (Analegsic, Anesthesia, Sedation ) / Dose given

Write the specific drug provided in the upper row and doses given in the lower row

Post abortion contraceptive

21 Counseled (√) Tick (√)yes if the client is counseled and tick no if the client is not counseled

22 Expressed desire (Y/N) Write Y=yes if the client expressed desire, N=No if the client express no desire


24 Repeat acceptor (√)Tick (√) if client is repeat acceptor at the time of registration. A repeat acceptor is someone who is not a new ac-ceptor; in other words, a repeat acceptor has received a contraceptive method from a recognized Provide before registration.

25 Contraceptive Method/s ProvidedWrite the specific type of contraceptive method provided Mc=Male condom, FeC=Female condom ,OC=Oral con-traceptive ,Ec=Emergency Contraceptive, Inj=Injectabile

HIV assessment

26 HIV test accepted (√) Tick (√) if HIV test is accepted

27 Target population Category write code

Write the code selecting from the list of target population category listed, an individual needs to be assigned only in one category that best describe him/her.



28 HIV test result(P or N) Write P for positive result and N for negative result

29 HIV test received with post test counseling(√) Tick if the HIV test result is received with post test counseling

30 HIV Positive Linked to ART Tick (√) if the woman is positive and linked to ART.

Outcome

31 Complications ( Yes-Specify or No) Specify if there is complication, if there is no complication write no.

32 Death (√) Tick (√) if the women died of abortion complication

33 Other treatment provided(√) Tick (√) if other treatment is provided

34 If other service provided write the codeWrite the code if the response is yes. 1. Counseling, 2. Screening, 3. Diagnosis and or treatment for other SRH needs. If not, tick no

35 Remarks/ Linkage to services etc Write any note or linkage that the provider require to document

36 Name & Signature of service provider Write full name and signature of the service provider

INSTRUCTIONS FOR COMPREHENSIVE ABORTION CARE REGISTRATION

Comprehensive Abortion Care Services Register

S.N Date MRN Age

Ges

tatio

nal a

ge (w

ks)

Gra

vida

Para

No.

of p

revi

ous

ab

ortio

ns

safe

abo

rtion

car

e(√)

post

abo

rtion

car

e(√)

Diagnosis/ Reason for safe*/post

abortion care**

Type of uterine evacuation Procedure (√)

Managed as

Refe

rred

(√) Drugs provided

(Analegsic, Anesthesia, Sedation )

/ Dose given

Postabortion Contraception

HIV assesment out come

Oth

er (√

) tre

atm

ent

prov

ided

if ot

her

serv

ice

prov

ided

wri

te th

e co

d(1,

2,3)

dia

gnos

is &

/or

trea

tmen

t fo

r ot

her

repr

oduc

tive

heal

th n

eeds

Remarks/ Linkage to

services etc

Name & Signature of service provider

Coun

sele

d(√)

Expr

esse

d de

sire

(√)

New

acc

epto

r (√

)

Repe

at a

ccep

tor(

√)Co

ntra

cepti

ve M

etho

d/s

Prov

ided

HIV

test

acc

epte

d(√)

Targ

et p

opul

ation

Ca

tego

ry w

rite

cod

eH

IV te

st re

sult(

P/N

)H

IV te

st re

ceiv

ed w

ith p

ost

test

cou

nsili

ng(√

)H

IV p

ositi

ves

linke

d to

A

RT(√

)Co

mpl

icati

ons

if ye

s (s

peci

fy)

or N

o

Dea

th (√

)

MVA

(√)

E&C(

√)

MA

(√)

D&

E(√)

Other

Out

-pt(

√)

In-p

t(√)

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 26 27 28 29 30 31 32 33 34 35 36

Count

safe abortion 10-14 Post abortion 10-14




safe abortion 30+ Post abortion 30+

Use Abbrevation for col 25Mc=Male condomFeC=Female condomOC=Oral contraceptiveInj=Injectabile

Col.34 Write code for Counseling=1 Screening=2 Diagnosis&treatment=3

* Reason for safe abortion: 1 Rape 2. Incest 3. Maternal condition 4. Fetal deformity ** Diagnosis for post abortion: A. Incomplete abortion B. Inevitable C. Missed D. Others

Targeted population category (27)A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVC



Health Centre /Clinic/Hospital Routine Immunization Register

Region Write the region where the facility is locatedWoreda / Sub-City Write the woreda/sub-city where the facility is located.Kebele If Health Post, write the name of the kebele where the Health Post is located.Name of Health Facility Write the name of the health facility where the EPI and GM services are provided.Register begin date Enter the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)


S. N Datum Comments

Identification: personal information 1 S. N Write sequential serial number in registration book;

2 Infant’s MRN Write infants Medical Record Number Unique individual identifier used on medical information folder

3 Name of infant Write the name of the infant

4 Date of birth Write Infant’s date of birth, written as (EC) Day/Month/Year (DD/MM/YY)

5 Sex(M/F) Write Child’s sex: M = Male; F=Female

6 Name of Mother Write the name of the mother

7 Mother’s MRNWrite Medical Record Number Unique individual identifier used on mother’s medical information folder Mothers

should be informed to come with their Td immunization card when they come for child immunization.

Identification: Address8 Woreda /Kebele Write Woreda in upper row and Kebele in the lower row

9 Gote/House number Write gote in the upper row and house number in the lower row

Registration 10 Reg. Date (DD/MM/YY) Date registered, written as (EC) Day/Month/Year (DD/MM/YY)

Immunization Services: Antigens Received 11 Dose number Indicates specific dose number of antigens

12 BCG Write Date BCG antigen received, written as (EC) Day/Month/Year (DD/MM/YY)

13 OPV (0-3) Write Date OPV antigens received in each row, written as (EC) Day/Month/Year (DD/MM/YY)

14HepB birth dose: within 24 hrs (DD/MM/

YY)Write Date HePB BD antigen received within 24 hrs (DD/MM/YY)

15HepB birth dose: after24 and below 14

days (DD/MM/YY)Write Date HePB BD antigen received after24 and below 14 days (DD/MM/YY)

16 DTP-HebB-Hib (1-3) Write Date DTP-HebB-Hib antigen received in each row, written as (EC) Day/Month/Year (DD/MM/YY)

17 PCV (1-3) Write Date PCV antigens received in each row, written as (EC) Day/Month/Year (DD/MM/YY)

18 Rota( 1-2) Write Date Rota antigens received in each row, written as (EC) Day/Month/Year (DD/MM/YY)

19 IPV (1-2) Write Date IPV antigen received, written as (EC) Day/Month/Year (DD/MM/YY) for both IPV1 and IPV2

20 MCV (1-2) Write Date MCV/Measles antigens received in each row, written as (EC) Day/Month/Year (DD/MM/YY)

21 Fully immunized (√) Tick if child completes full series of immunizations by first Birthday

Immunization Service: Neonatal tetanus protection

22No. of Td doses Mother received in last

Pregnancy

Write number of Td doses mother received in last pregnancy (Quality check for PAB in column 22: either column 20 or

21, but nor both, should be ticked if PAB (column 22) is ticked.)

Infant is considered if mother received a total of 3 or more doses in column 21 or if mother has received 2 doses in

her last pregnancy

23 Total No. of Td doses Mother received Write total number of Td doses mother received any time (See note on column 20 for purpose of this column.)

24Protected from neonatal tetanus at

birth (PAB) (√)

Tick if mother received 2 doses of Td in last pregnancy or a total of 3 doses at any time (Quality check for PAB : either

2 doses in column 20 or 3 or more doses in column 21)

Associated Services

25Nutrtional screening date (DD/MM/YY) Write the Date of child growth was monitored, written as (EC) Day / Month / Year (DD/MM/YY)

Screened & linked to CINuS (√) Tick (√) if child screened for nutritional status and linked to CINuS

26 Developmental milestone assessmentScreen and write the Developmental milestone status, write code: “NDD”- No Developmental Delay; “SDD”

-Suspected developmental delay; or “DD”: -Developmental delay

27 Remarks Appointment / other comments

INSTRUCTIONS FOR ROUTINE IMMUNIZATION REGISTRATION AT ALL FACILITIES

Record immunization at all levels until child completes immunizations


Identification

Registra-tion

Routine Immunization Register Associated services

Rem

ark/

Appo

intm

ent

Personal informationAddress Antigens received Neonatal tetanus pro-

tectionNutrtional screening date (DD/MM/YY)

Develomp-ment

milstones assess-ment

Write code

Woreda Gott

Dose num-ber

BCG (DD/MM/

YY)

OPV (DD/MM/YY)

Hep Birth dose

DPT-Hep-Hib (Pentavalent) (DD/MM/YY)

PCV (DD/MM/YY)

Rota (DD/MM/YY)

IPV (DD/MM/YY)

Measles (DD/MM/YY)

Fully im-munized

(√)

No. of Td doses Mother received

in last pregnan-

cy

Total No. of

Td doses Mother received

Pro-tected at birth (PAB)

(√)S.N

Infant’s MRN Name of infant

Date of Birth (DD/MM/

YY)

Sex (M/F) Name of mother Mother’s

MRN KebeleHouse Num-

ber

Reg. Date (DD/MM/

YY)

within 24 hrs (DD/MM/YY)

after24 and be-low 14 days (DD/

MM/YY)

Screened & linked to CINuS (√)

(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) (26) (27)

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

Count # of children with

NDD SDD

DD

ROUTINE IMMUNIZATION REGISTER

Develompment milstones assessment classification code (Col. 26) NDD- No Developmental Delay SDD -Suspected developmental delay DD: -Developmental delay


Health Centre /Clinic/Hospital HPV Immunization Register

Region Write the region where the immunization is provided

Woreda / Sub-City Write the woreda/sub-city where the immunization is provided

Kebele If school, write the name of the kebele where the school is located.

Name of school Write the name of the school where the HPV service are provided.



S. N Datum Comments

Identification: personal information 1 S.N Write Sequential serial number in registration book

2 MRN Write Medical Record Number Unique individual identifier used on medical information folder

3 Girl’s Name Write the name of the girl

3 Date of birth(DD/MM/YY) Write the date of birth (EC) Day/Month/Year (DD/MM/YY)

5 Age Write Girl’s age,

6 In school (Grade) Write the grade if she is student

7 Out of school(√) Tick if she is out of school

Identification: Address8 Woreda Write the Woreda

9 Kebele Write the Kebele

10 Ketena/Gott Write the Gott or Ketena or village name

11 House No. Write the house number

Registration 12 Reg. Date (DD/MM/YY) Write registration date as Day/Month/Year (DD/MM/YY)

Immunization Services: HPV antigens Received Girl 13 HPV 1 Write the Date antigen received, written as (EC) Day/Month/Year (DD/MM/YY)

14 HPV 2 Write the Date antigen received, written as (EC) Day/Month/Year (DD/MM/YY)


INSTRUCTIONS FOR HPV IMMUNIZATIONRegister the girl, with Health Card retained by girl/client.Location information to be completed at front of register:

Identification Registration Date

(DD/MM/YY)

Vaccination service Remark/ Appoint-

ment

Personal information Address

HPV -1 (DD/MM/YY)

HPV -2 (DD/MM/YY)S.N MRN Full Name of the Girls

Date of Birth (DD/MM/YY) Age

In school (Grade)

Out of school (ü) Woreda Kebele Gott

House No.

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10 (11) (12) (13) (14) (15)

count

HPV IMMUNIZATION REGISTER


Health Centre /Clinic/Hospital Tetanus Diphtheria Register

Location information to be completed at front of register:Region Write the region where the facility is locatedWoreda / Sub-City Write the woreda/sub-city where the facility is located.Kebele If Health Post, write the name of the kebele where the Health Post is located.Name of Health Facility Write the name of the health facility where the Td and Vit A services are provided.Register begin date Enter the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Enter the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

S. N Datum CommentsIdentification: personal information 1 S.N Write Sequential serial number in registration book

2 MRN Write Unique individual identifier used on medical information folder

3 Name Write the name of the client

4 Age Write Client’s age

Identification: Address5 Woreda Write the Woreda


7 Ketena/Gott Write the Gott or Ketena

Registration 8 Reg. Date (DD/MM/YY) Write registration Date written as Day/Month/Year (DD/MM/YY) (EC)

Immunization Services: Tetanus Diphtheria Antigens Received Pregnant women9 Td 1 Write Date Td 1 antigen received, written as (EC) Day/Month/Year (DD/MM/YY)

10 Td 2 Write Date Td 2 antigen received, written as (EC) Day/Month/Year (DD/MM/YY)



13 Td5 Write Date Td 5 antigen received, written as (EC) Day/Month/Year (DD/MM/YY)

Immunization Services: Td Antigens Received Non-pregnant women14 Td 1 Write Date Td 1 antigen received, written as (EC) Day/Month/Year (DD/MM/YY)




18 Td5 Write Date Td 5 antigen received, written as (EC) Day/Month/Year (DD/MM/YY)


INSTRUCTIONS FOR Td IMMUNIZATION REGISTER

IdentificationRegistration Pregnant Women Immunization Non-Pregnant Women Immunization

Remark /Appointment

Personal information Address

Serial No.

MRN Name Age Woreda Kebele Gott

Reg. Date (DD/MM/YY)

Td1 (DD/MM/YY)

Td2 (DD/MM/YY)

Td3 (DD/MM/YY)

Td4 (DD/MM/YY)

Td5 (DD/MM/YY)

Td1 (DD/MM/YY)

Td2 (DD/MM/YY)

Td3 (DD/MM/YY)

Td4 (DD/MM/YY)

Td5 (DD/MM/YY)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)

Tetanus Diphtheria Register


Hospital / ClinicNeonatal Intensive Care Unit (NICU)

Register

Register for Hospitals with neonatal Intensive care unit onlyLocation information to be completed at front of register:



Name of Health Facility Write the name of the health facility where the NICU services are provided.

NICI- level Write the level as (I),(II ),(III)



Patient’s informationCol. Datum CommentsIdentification1 S.N Write Sequential serial number in registration book

2 MRN WriteUnique individual identifications used on medical information folder fill only at HC and hospital.

3 Name of newborn Write the connotation “Baby” followed by the mother’s name. E.g “Baby Asede”

4 Sex (M/F) Write Child’s sex: M=Male; F=Female

5 Name of the mother Write the full name of the newborn’s mother (Name, Father’s name, grandfather’s name)

6 Zone/Woreda Write Zonein upper row and Woreda in the lower row7 Kebele/Gote Write Kebele in upper row and Gote in the lower rowAdmission Information

8Admission Date and Time (DD/MM/YY - 00:00)

Write the date the newborn has been admitted to the NICU (In Ethiopian calendar with Day / Month / Year) AND write the time the newborn has been admitted to the NICU (In Ethiopian time, Hour/minute)

9 Admission Weight (gm) Write the weight of the newborn at the time of admission to the NICU in grams

10 Temperature (0C) Write the temperature of the newborn at the time of admission in degree Celsius (0C)

11 Respiratory Rate (RR) per ‘ Write how many times the newborn breathes per one minute at a time of admission.( #/minute)

12Apical Heart Rate(AHR) per ’

Write how many times the newborns heart beats per one minute at a time of admission (#/minute)

Delivery Information13 Gestational Age (in weeks) Write the gestational age the of the newborn by using Ballard’s scoring method (Write the estimation in Weeks)

14Delivery Date and Time (DD/MM/YY - 00:00)

Write the date of the newborn (In Ethiopian Calendar, with Date/Month/Year) AND write the time the newborn was born (Ethiopian time, with Hour/minute)

15Mode of delivery write code

Write the code for newborn mode delivery 1.Spontanous2. CS3.instumental

16Place of deliverywrite the code

Write the code for newborn place of delivery 1.Home delivery, 2.Same Facility, 3.Refered from other facility

17APGAR Score 1’/5’ (At birth)

Write the APGAR score of the newborn at the first and fifth minute of birth (1st minute /5th minute)

18 Birth weight (gm) Write the weight of the newborn at the time of delivery in gram

Maternal Condition19 PITC (P/N) Write P if the mother of the newborn is HIV positive and write N if the mother of the newborn is HIV negative

20 Hepatitis B (P/N) Write P if the Mother is Positive for Hepatitis B surface antigen AND write N if the mother is negative to Hepatitis B surface antigen (HBsAg)

21 Hepatitis C (P/N) Write P if the Mother is Positive for Hepatitis C antibody AND write N if the mother is negative to Hepatitis C antibody (HCAb)

22 VDRL (R/NR) Write R if the VDRL (venereal disease research laboratory) test for syphilis for the mother is Reactiveor write NR if Not reactive

23 A= Alive /D =died Write the code A if the mother is alive and D if the mother is died

Admission Problem (24-32)

24 Prematurity (✓)Tick(✓)if the newborn is diagnosed with prematurity (Born less than 37th week of gestation) OR (If less than 37 week of gestation by Ballard’s scoring)

25 LBW (low birth weight) (✓) Tick (✓)if the newborn is diagnosed with Low Birth Weight (if less than 2500gms)

26 Sepsis (✓) Tick (✓)if the newborn is diagnosed with sepsis

27Respiratory Distress syndrome (✓)

Tick(✓)if the newborn is diagnosed with Respiratory distress syndrome (RDS)

28Perinatal Asphyxia (PNA) (✓)

Tick(✓)if the newborn is diagnosed with Perinatal Asphyxia (PNA)

29Congenital Malformation (✓)

Tick (✓)if the newborn is diagnosed to have any form of congenital Malformation

30Meconium Aspiration syndrome (✓)

Tick (✓) if the newborn is diagnosed with meconium aspiration syndrome

31 Hyperbilirubinemia (✓) Tick (✓) if the newborn is diagnosed with hyperbilirubinemia

32 Other (specify) Write if the newborn is diagnosed with other problem(specify) during admission

Managements (33-44)

33Continuous Positive Air way Pressure CPAP (✓)

Tick(✓)if the newborn is treated with Continuous Positive Air way Pressure CPAP

34 Resuscitation (✓) Tick (✓)if the newborn is resuscitated with Bag and Mask

35Prolonged skin to skin thermal care (KMC)

Tick(✓)if KMC (kangaroo mother care) was initiated for the newborn

36 Antibiotics (✓) Tick(✓)if the newborn is treated with any form of antibiotic

37 Anticonvulsants (✓) Tick(✓)if the newborn is treated with anticonvulsant

38 Phototherapy (✓) Tick (✓)if the newborn has received phototherapy treatment

39 Glucose (✓) Tick(✓)if the newborn is treated with Glucose after admission

40 O2 (oxygen) (✓) Tick(✓)if the newborn is treated with oxygen (With nasal prong or face-mask)

41 Blood Transfusion (✓) Tick(✓)if the newborn has received blood transfusion

42 Incubator thermal care(✓) Tick (✓)if the newborn was placed in an incubator for treatment

43 Exchange transfusion (✓) Tick(✓) if the newborn has received exchange transfusion

44 Other (specify) Write if the newborn is diagnosed with otherproblem (specify) during treatment.

Discharge Information(45-50)

45Discharge Date and Time (DD/MM/YY - 00:00)

Write the date the newborn has been discharged from the NICU (In Ethiopian calendar with Day / Month / Year) AND write the time the newborn has been discharged from the NICU (In Ethiopian time, Hour/minute)

46 Weight at Discharge (gm) Write the weight of the Newborn at the time of discharge in grams (gm)

47Discharge status write code

Write the code for treatment outcome of the newborn1. Recovered 2. Died 3.Transfered3.Others (specifylike: Absconded,Left against medical advice…….)

48Survived after resuscitation (✓)

Tick(✓) the box below only if the Newborn has received resuscitation at the NICU and his/her condition has improved.

49If died, (age in hours/ days)

Write age in hours or days if died

50 Cause of Death Write code for cause of death 1. Prematurity 2. Sepsis 3. Prenatal Asphyxia 4. Congenital Malformation 5. Other (specify)

51 Length of stay /LOS/ (days) Write Length of stay in days

Counseling on care for child(52-54)

52 Counseled on Breast feeding/nutrition (✓)

Tick(✓) if the caregiver counseled on breast feeding/Nutrition

53Counseled on Newborn care (✓)

Tick(✓) if the caregiver counseled on Newborn care

54Counseled on Early Childhood Development (ECD)(✓)

Tick(✓) if the caregiver counseled on Early childhood development

55 Remark If there is any additional, information that the provider thinks should be mentioned can be filled here. (referred to/referred from)

Identification Admission Information Delivery Information Maternal Condition

S.N MRN Name of newborn

Sex

(M/F

)

Name of mother

Zone Kebele Admission date and

Time (DD/MM/YY - 00:00)

Admission Weight (gm)

Tem

pera

ture

(0C

)

Risp

irato

ry R

ate

per

‘

Api

cal H

eart

Rat

e pe

r ‘

Ges

tatio

nal A

ge (w

eeks

)

Delivery date and

Time (DD/

MM/YY - 00:00)

Mod

e of

del

iver

y w

rite

co

de

Plac

e of

del

iver

y w

rite

co

de

Apg

ar S

core

1’/

5’

Birth weight (gm) PI

TC (P

/N)

Hep

titis

B (P

/N)

Hep

etitis

C (P

/N)

VDRL

(P/N

)

A =

Aliv

e or

D =

Dea

d

Woreda Gote

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23)

Count Total admission

count Low birth weight

Neonatal Intensive Care Unit (NICU) Register

Mode of delivery code Col(15)1.Spontanous2. CS3.Instumental

Place pf Delivery: col(16)1. Home deliver 2. Same facility; 3. Referred from other facility4. Other

Neonatal Intensive Care Unit (NICU) RegisterAdmission Problem Manegment Discharge Information Counseled on

Remark/ Referred from or referred to

Prem

atur

ity (✓

)

Low

bir

th w

eigh

t ( ✓

)

Seps

is ( ✓

)

RDS

( ✓)

Peri

nata

l Asp

hyxi

a(✓

)

Cong

. Mal

form

ation

( ✓)

Mec

oniu

m A

spira

tion

syn-

drom

e (✓

)

Hyp

erbi

lirub

inem

ia (✓

)

Oth

er (s

peci

fy)

CPA

P (✓

)

Resu

scita

tion

( ✓)

KMC

( ✓)

Anti

bioti

cs (

✓)

Anti

conv

ulsa

nts

( ✓)

Phot

othe

rapy

(✓

)

Glu

cose

( ✓)

O2

(oxy

gen)

( ✓)

Bloo

d Tr

ansf

usio

n ( ✓

)

Incu

bato

r/th

erm

al c

are(

✓)

Exch

ange

tran

sfus

ion

( ✓)

Oth

er (s

peci

fy)

Discharge Date and Time (DD/MM/YY -

00:00)

Discharge weight (gm)

Dis

char

ge s

tatu

s w

rite

co

de

Surv

ived

a

fter

resu

sita

tion

( ✓)

If di

ed,

(age

in h

ours

or

days

)

cau

se o

f dea

th w

rite

cod

e

Leng

th o

f sta

y /L

OS/

(day

s)

Brea

st fe

edin

g/nu

triti

on

(✓)

New

born

car

e (✓

)

Earl

y Ch

ildho

od D

evel

op-

men

t/EC

D (

✓)

(24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55)

count # of deaths

Sepsis KMCRecovered Resucitated and

Survived

Within 0-24hrs LOS

Dead Within 1-7 days

Transferred Within

7 -28 days

Other

Cause of death: Col (49)1. Prematurity; 2. Sepsis3. prenatal Asphyxia4. Congenital Malformation5. Other (specify)

Discharge status: col (47) 1. Recovered; 2. Died; 3. Transfered; 4. Others (specify)


Health Centre /Clinic/Hospital Integrated Management of New born and Childhood

Illness Register (2 to 59 Months) Register

1. A row separated by a hard line is for one patient. The very top row indicates which variable to fill, like name of patient, age, sex, weight, etc….

2. Some boxes are separated by dotted line. In these boxes two variables should be written. Example: in the first column, the first box is divided into two by dotted line. According to

the very top row, in the upper box the date of the visit should be filled and in the lower box the serial number should be filled. The same applies for the third, fourth and fifth columns.

In the third column name above and address below, in the fourth column age above and sex below, in the fifth column weight above and temperature below.

3. In the presenting complaint box the most important reason/s for the visit should be written clearly.

4. In the patient’s signs and symptom boxes all signs or symptoms the child has should be circled or written.

5. Write clearly in the columns for other problem, classification/s, medicine/s, referral, follow-up and other remarks.

6. Use all the information you noted to classify the child and provide medicine/s, referral or follow-up.

7. Do follow up to all sick young infants and children and document the outcome of your efforts

8. Write the diagnosis (name and code) based on Ethiopia Simplified Version International Classification of Disease (ESV_ICD11) as it appears on the hand book Table on computer

(do not abbreviation)

INSTRUCTION ON HOW TO COMPLETE THE UNDER-FIVE REGISTER

Integrated Management of New born and Childhood Illness Register (2 to 59 Months)Date

Medical re-cord (card)

No.

Name Age Weight

Presenting Complaint

Patient’s Signs and Symptoms If sign present, circle the variables and write figures when needed

Patient’s Signs and Symptoms If sign present, circle the variables and write figures when needed Other

Prob-lems

Classification

Treatment, Counsel and Follow Up [ESV_ICD11] Diagnosis

RemarksSeri-al No

Address Sex

Height Medicine (Name, Dose,

Schedule, Duration)

Counsel and Referral Follow up (Woreda/ Ke-

bele) Temp Check General Danger Signs

Cough or Difficult Breathing Diarrhoea Fever Ear Problem Check Malnutrition and Anemia Feeding Assessment HIV/AIDS Tuberculosis Development Immunization, Vit A

and Deworming Name CodeYes No Yes No Yes No Yes - Hist / Feel / Temp No Yes No *WFH: <-3Z, -3 to <-2Z, ≥ -2Z Yes No * Mother:

Positive Negative Unknown * Child Anti-body: Positive Negative Unknown * Child DNA PCR: Positive Negative Unknown * Br F in last 6 wks: Yes No

* Cough > 14 days ‘* Fever/night sweats > 14days ‘* Weight loss or failure to gain ‘* Contact with PTB patient ‘* Swelling or discharging wound ‘* MAM or SAM ‘* HIV: Pos Neg Unknown ‘* Gene Xpert/AFB Pos Neg Not Done ‘* Chest XR: Suggestive NOT Suggestive Not Done

*Is there any risk factors and/or parental concerns related to the

child development? Yes No

If Yes, ___________________ _________________________ ________________________

‘* Current age milestone/s: Absent: Yes No

‘* Earlier age milestone/s: Absent: Yes No

‘* Lost previously acquired ability/

ies: Yes No

* Immunization (<24 mth): Completed, Upto date, Not Upto date, Defaulted, Not Started, ‘* Vitamin A (≥6 mth): Upto date Not Upto date ‘* Albendazole or Mebendazole (≥24 mth): Upto date Not Upto date

Yes No

* Counsel mother: Food Fluid When to return Immediately: * Early Child Development (ECD) * If referred, Name of HC/ Hospital or service if referred to the service in the same institution:: ________________ ________________ ________________ ________________

* Follow up date: _________________ * Follow up Outcome Improved Same Worsened * Follow up Action:

_____ _____ ‘* ________ days * ________days ; * Malaria Risk - High / Low / No * MUAC: <11.5, 11.5 - <12.5, ≥12.5cm

* Feeding Problem: Yes No ‘* If Yes, ______________ ______________ ______________ _____________

months kg

‘* Unable to drink or Breastfeed

‘* Respiratory rate ‘_______ /minute Fast Breathing

* Blood in stool * Lethargic/ unconscious * Restless/ Irritable

If No, Travel history in 1 month - Yes ‘* Fever duration ________ days ‘ If > 7 days, Fever every day ‘* History of measles within 3 month

* Ear Pain * Ear discharge ______ days

* Oedema: +, ++, +++ * Medical complications: Yes/No

* Vomits everything * Chest Indrawing * Sunken eyes * Stiff neck *Bulged fontanell (<1yr) * Pus Draining_____ * Convulsion history * Stridor * Unable / drinks poorly * Generalized rash- * Tender Swelling

M cm * Convulsing now * Wheeze * Drinks eagerly/thirsty - Cough / Runny nose / Red eyes behind the ear * Appetite test: Passed Failed* Lethargic/ * Oxygen Saturation * Skin Pinch- * Mouth ulcers / Deep or Extensive

F _____ Unconscious _______ % Very Slowly * Eye: Pus draining / Corneal clouding Palmar pallor: Severe, Some, No

o C Slowly * BF : ____________________ Hgb: ______ gm/dL HCT: ______ %

Yes No Yes No Yes No Yes - Hist / Feel / Temp No Yes No *WFH: <-3Z, -3 to <-2Z, ≥ -2Z Yes No * Mother: Positive Negative Unknown * Child Anti-body: Positive Negative Unknown * Child DNA PCR: Positive Negative Unknown * Br F in last 6 wks: Yes No




If Yes, ___________________ _________________________ ________________________




ies: Yes No


Yes No



_____ _____ ‘* ________ days * ________days ; * Malaria Risk - High / Low / No * MUAC: <11.5, 11.5 - <12.5, ≥12.5cm * Feeding Problem: Yes No ‘* If Yes, ______________ ______________ ______________ _______________

months kg






* Oedema: +, ++, +++ * Medical complications: Yes/No * Vomits everything * Chest Indrawing * Sunken eyes * Stiff neck *Bulged fontanell (<1yr) * Pus Draining

_____ * Convulsion history * Stridor * Unable / drinks poorly * Generalized rash- * Tender Swelling

M cm * Convulsing now * Wheeze * Drinks eagerly/thirsty - Cough / Runny nose / Red eyes behind the ear * Appetite test: Passed Failed

* Lethargic/ * Oxygen Saturation * Skin Pinch- * Mouth ulcers / Deep or Extensive

F _____ Unconscious _______ % Very Slowly * Eye: Pus draining / Corneal clouding Palmar pallor: Severe, Some, No o C Slowly * BF : ____________________ Hgb: ______ gm/dL HCT: ______ %





If Yes, ___________________ _________________________ ________________________




ies: Yes No


Yes No




months kg









* Lethargic/ * Oxygen Saturation * Skin Pinch- * Mouth ulcers / Deep or ExtensiveF _____ . __ Unconscious _______ % Very Slowly * Eye: Pus draining / Corneal clouding Palmar pallor: Severe, Some, No


Integrated Management of New born and Childhood Illness Register (2 to 59 Months)Date

Medical re-cord (card)

No.

Name Age Weight

Presenting Complaint

Patient’s Signs and Symptoms If sign present, circle the variables and write figures when needed

Patient’s Signs and Symptoms If sign present, circle the variables and write figures when needed Other

Prob-lems

Classification

Treatment, Counsel and Follow Up [ESV_ICD11] Diagnosis

RemarksSeri-al No

Address Sex

Height Medicine (Name, Dose,

Schedule, Duration)

Counsel and Referral Follow up (Woreda/ Ke-

bele) Temp Check General Danger Signs

Cough or Difficult Breathing Diarrhoea Fever Ear Problem Check Malnutrition and Anemia Feeding Assessment HIV/AIDS Tuberculosis Development Immunization, Vit A

and Deworming Name CodeYes No Yes No Yes No Yes - Hist / Feel / Temp No Yes No *WFH: <-3Z, -3 to <-2Z, ≥ -2Z Yes No * Mother:

Positive Negative Unknown * Child Anti-body: Positive Negative Unknown * Child DNA PCR: Positive Negative Unknown * Br F in last 6 wks: Yes No




If Yes, ___________________ _________________________ ________________________




ies: Yes No


Yes No



_____ _____ ‘* ________ days * ________days ; * Malaria Risk - High / Low / No * MUAC: <11.5, 11.5 - <12.5, ≥12.5cm

* Feeding Problem: Yes No ‘* If Yes, ______________ ______________ ______________ _____________

months kg






* Oedema: +, ++, +++ * Medical complications: Yes/No

* Vomits everything * Chest Indrawing * Sunken eyes * Stiff neck *Bulged fontanell (<1yr) * Pus Draining_____ * Convulsion history * Stridor * Unable / drinks poorly * Generalized rash- * Tender Swelling

M cm * Convulsing now * Wheeze * Drinks eagerly/thirsty - Cough / Runny nose / Red eyes behind the ear * Appetite test: Passed Failed* Lethargic/ * Oxygen Saturation * Skin Pinch- * Mouth ulcers / Deep or Extensive

F _____ Unconscious _______ % Very Slowly * Eye: Pus draining / Corneal clouding Palmar pallor: Severe, Some, No






If Yes, ___________________ _________________________ ________________________




ies: Yes No


Yes No




months kg









* Lethargic/ * Oxygen Saturation * Skin Pinch- * Mouth ulcers / Deep or Extensive

F _____ Unconscious _______ % Very Slowly * Eye: Pus draining / Corneal clouding Palmar pallor: Severe, Some, No o C Slowly * BF : ____________________ Hgb: ______ gm/dL HCT: ______ %





If Yes, ___________________ _________________________ ________________________




ies: Yes No


Yes No




months kg









* Lethargic/ * Oxygen Saturation * Skin Pinch- * Mouth ulcers / Deep or ExtensiveF _____ . __ Unconscious _______ % Very Slowly * Eye: Pus draining / Corneal clouding Palmar pallor: Severe, Some, No


Disease type CountPneumonia Rxed with antibiotic Diarrhea treated with ORS and zincDiarrhea Rxed with ORS only

StatusCount by Age

0-24 months 25-59 monthsDDSDDNDD


Health Centre /Clinic/Hospital Integrated Management of New born and Childhood

Illness Register (from 0-2 months)

1. A row separated by a hard line is for one patient. The very top row indicates which variable to fill, like name of patient, age, sex, weight, etc….

2. Some boxes are separated by dotted line. In these boxes two variables should be written. Example: in the first column, the first box is divided into two by dotted line. According to

the very top row, in the upper box the date of the visit should be filled and in the lower box the serial number should be filled. The same applies for the third, fourth and fifth columns.

In the third column name above and address below, in the fourth column age above and sex below, in the fifth column weight above and temperature below.

3. In the presenting complaint box the most important reason/s for the visit should be written clearly.

4. In the patient’s signs and symptom boxes all signs or symptoms the child has should be circled or written.

5. Write clearly in the columns for other problem, classification/s, medicine/s, referral, follow-up and other remarks.

6. Use all the information you noted to classify the child and provide medicine/s, referral or follow-up.

7. Do follow up to all sick young infants and children and document the outcome of your efforts

8. Write the diagnosis (name and code) based on Ethiopia Simplified Version International Classification of Disease (ESV_ICD11) as it appears on the hand book Table on computer

(do not abbreviation)

INSTRUCTION ON HOW TO COMPLETE THE UNDER-FIVE REGISTER

Integrated Management of New born and Childhood Illness Register (from 0-2 months) Date

Medical re-cord (card )

No.

Name Age Wt.Presenting Complaint

Presenting Complaint Birth Asphyxia

Gestational Age Signs and Symptoms (Circle/write as needed in respective spaces) Signs and Symptoms (Circle/write ...)Immuniza-tion Status

of Infant

Other ProblemsClassification

Treatment Follow up Date [ESV_ICD11] Diagnosis Remarks

Serial NoAddress (Woreda/ Kebele)

SexLt

Weight: (First 7 Days) Very Severe Disease and Local Bacterial Infection Jaundice Diarrhoea HIV/AIDS Feeding Problem (For Breast-

feeding ) Development problem Medicine (Name, Dose, Schedule, Duration) Counsel the Mother

Referred (Name of HC/

Hosp)Outcome

Temp Maternal Danger Signs (< 6wks) Name Code

Gestational age: * unable to feed Yes No HIV test: * Any Breastfeeding difficulty

‘*Is there any risk factor and/or parental concern related to

the child development? Yes No

If Yes, ___________________

________________________

Up to date

Not up to date

Not Started

Yes No

Not breathing <32 wks * Not feeding well * Yellow: * _____ days * Mother: Positive * <8 breastfeeds in 24hrs * Breast

____ ____ 32 - <37 wks * Convulsions - Palms &/or soles * Blood in the stool Negative * Switching breast frequently feeding

wks gms Not crying ≥ 37 wks * RR ____/min Fast breathing - Face or eyes * Moves only when stimulated unknown * Not increasing BF during illness

* Severe chest indrawing - No yellowness * No Movement when stimulated * Child: ANTIBODY * Receives other foods/drinks * Keep * Improved

Gasping Weight: * Umbilicus: Red / Pus draining * Restless/Irritable Positive * Underweight (Wt /Age) warm

M ____ <1,500 gms * Temp ≥37.5°C (feels hot ) * Age * Sunken eyes Negative * Mouth ulcers/thrush * Same

cm Breathing <35.5°C (feels cold) - < 24hr or * Skin Pinch Unknown * Mother not breastfeeding

Current age milestone/s: Ab-sent: Yes No Yes No

* Early ChildDevel-opment (ECD)

F poorly 1,500 - <2,500gms * Skin pustules - 24hr - < 14 days Slowly * Child: DNA PCR * Positioning Good/ Poor * Worsened____ (<30 /min) * Moves only when stimulated - > 14 days Very Slowly Positive * Attachment Good/ Poor/ No

o C ≥ 2500 gms * No Movement when stimulated Negative * Suckling Good/ Poor/ No * When to Unknown * No Feeding Problem / Not UWt return

Gestational age: * unable to feed Yes No HIV test: * Any Breastfeeding difficulty‘*Is there any risk factor and/

or parental concern related to the child development?

Yes No If Yes,

___________________ ________________________

Up to date

Not up to date

Not Started

Yes No

Not breathing <32 wks * Not feeding well * Yellow: * _____ days * Mother: Positive * <8 breastfeeds in 24hrs * Breast ____ ____ 32 - <37 wks * Convulsions - Palms &/or soles * Blood in the stool Negative * Switching breast frequently feedingwks gms Not crying ≥ 37 wks * RR ____/min Fast breathing - Face or eyes * Moves only when stimulated unknown * Not increasing BF during illness

* Severe chest indrawing - No yellowness * No Movement when stimulated * Child: ANTIBODY * Receives other foods/drinks * Keep * ImprovedGasping Weight: * Umbilicus: Red / Pus draining * Restless/Irritable Positive * Underweight (Wt /Age) warm





F poorly 1,500 - <2,500gms * Skin pustules - 24hr - < 14 dd Slowly * Child: DNA PCR * Positioning Good/ Poor * Worsened____ . __ (<30 /min) * Moves only when stimulated - > 14 days Very Slowly Positive * Attachment Good/ Poor/ No




Yes No If Yes,

___________________ ________________________

Up to date

Not up to date

Not Started

Yes No



Gasping Weight: * Umbilicus: Red / Pus draining * Restless/Irritable Positive * Underweight (Wt /Age) warmM ____ <1,500 gms * Temp ≥37.5°C (feels hot ) * Age * Sunken eyes Negative * Mouth ulcers/thrush * Same






DateMedical re-cord (card )

No.

Name Age Wt.Presenting Complaint

Presenting Complaint Birth Asphyxia

Gestational Age Signs and Symptoms (Circle/write as needed in respective spaces) Signs and Symptoms (Circle/write ...)Immuniza-tion Status

of Infant

Other ProblemsClassification

Treatment Follow up Date [ESV_ICD11] Diagnosis Remarks

Serial NoAddress (Woreda/ Kebele)

SexLt

Weight: (First 7 Days) Very Severe Disease and Local Bacterial Infection Jaundice Diarrhoea HIV/AIDS Feeding Problem (For Breast-

feeding ) Development problem Medicine (Name, Dose, Schedule, Duration) Counsel the Mother

Referred (Name of HC/

Hosp)Outcome

Temp Maternal Danger Signs (< 6wks) Name Code

Gestational age: * unable to feed Yes No HIV test: * Any Breastfeeding difficulty

‘*Is there any risk factor and/or parental concern related to

the child development? Yes No

If Yes, ___________________

________________________

Up to date

Not up to date

Not Started

Yes No

Not breathing <32 wks * Not feeding well * Yellow: * _____ days * Mother: Positive * <8 breastfeeds in 24hrs * Breast

____ ____ 32 - <37 wks * Convulsions - Palms &/or soles * Blood in the stool Negative * Switching breast frequently feeding

wks gms Not crying ≥ 37 wks * RR ____/min Fast breathing - Face or eyes * Moves only when stimulated unknown * Not increasing BF during illness


Gasping Weight: * Umbilicus: Red / Pus draining * Restless/Irritable Positive * Underweight (Wt /Age) warm





F poorly 1,500 - <2,500gms * Skin pustules - 24hr - < 14 days Slowly * Child: DNA PCR * Positioning Good/ Poor * Worsened____ (<30 /min) * Moves only when stimulated - > 14 days Very Slowly Positive * Attachment Good/ Poor/ No




Yes No If Yes,

___________________ ________________________

Up to date

Not up to date

Not Started

Yes No


* Severe chest indrawing - No yellowness * No Movement when stimulated * Child: ANTIBODY * Receives other foods/drinks * Keep * ImprovedGasping Weight: * Umbilicus: Red / Pus draining * Restless/Irritable Positive * Underweight (Wt /Age) warm









Yes No If Yes,

___________________ ________________________

Up to date

Not up to date

Not Started

Yes No



Gasping Weight: * Umbilicus: Red / Pus draining * Restless/Irritable Positive * Underweight (Wt /Age) warmM ____ <1,500 gms * Temp ≥37.5°C (feels hot ) * Age * Sunken eyes Negative * Mouth ulcers/thrush * Same






Integrated Management of New born and Childhood Illness Register (from 0-2 months)

Sx Type Count Sx type Count

Critical cases Peneumonia Rxed with antibiotic

VSD cases Diarrhea treated with ORS and zinc

LBI cases Diarrhea Rxed with ORS only


Health Centre /Clinic/Hospital Adolescent Nutrition Register




Name of Health Facility Write the name of the health facility where the service was provided.Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)


Col. Number Data Elements Description

1 S.N Sequential serial number in registration book; to be entered on client’s registration card for later identification in the register 2 MRN Write Medical Record Number(MRN) 3 Child full name Write full name of the Adolescent 4 Woreda/ Kebele Write Woreda in upper row and Kebele in the lower row

5 Gott/Ketena Write Gott or ketene

6 Age (MM)/Sex ( M/F) Write the exact age of the Adolescents in complete Year(YY) in upper row and Adolescents Sex: M=Male; F= Female in the lower row 7 Dose_1(DD/MM/YY) Write de-worming Dose 1 received date ,month and year like (DD/MM/YY) in Ethiopian calendar year

8 Dose_2(DD/MM/YY) Write de-worming Dose 2 received date month and year like (DD/MM/YY) in Ethiopian calendar year

9 Nutritional Screening

Nutrition screening status

1.Date of Visit: Write Day only in the month

2. BMI: calculate BMI = age weight in Kg divided by height in m2 (Kg/m2)

3. Classification code

Normal(N): BMI 18.5-24.9, Under weight(U) : BMI 16-18.5 , Overweight (O): BMI 25-29.9 , Obese(Ob) : BMI 30-39.9 Very obese(VOb): BMI >=40 )

10-21 Month Write the date of visit in DD form ,BMI and code of nutritional screening classification22 Weekly Iron Folic Acid(IFA)

23-47 W1 w2 w3 w4 Write Date (DD/MM/YY) in Ethiopian format for each week in month W1 stands for week one and …..

47 Remark Write any point that is relevant but not recorded in any column above

Instruction for Adolescent Nutrition Register

Personal Identification Deworming Nutrition Screening for adolescent Week-ly_IFA

Month__________ Month__________ Month__________ Month__________ Month__________ Month__________

RemarkS.N MRN Full Name

Woreda /

Kebele

Got or Ketena

Age/ Sex-

(F/M)

Dose-1 (DD/MM/

YY)

Dose-2 (DD/MM/

YY)

Nutritional Screening Ham Neh Mes Tik Hid Thas Tir Yek Meg Miaz Ginb Sen W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

Date of Visit (Write Day only)

Date (DD/MM/YY)

BMI for age

Classification write code (N,U,O, Ob,Vob)


Date (DD/MM/YY)

BMI for age



Date (DD/MM/YY)

BMI for age



Date (DD/MM/YY)

BMI for age



Date (DD/MM/YY)

BMI for age



Date (DD/MM/YY)

BMI for age


Count Dose 1

Count Dose 2

Count : Count:

Normal(N)Adolsecent who received IFA tablets for four conscuative weeks in the reporting period

Under Weight(U)

Over Weight(O)

Obes(Ob)

Very Obes(VOb)

Adolescent Nutrition Register


Health Centre /Clinic/Hospital Integrated Adolescent and Youth

Health Service Register


Region Write region name where the facility is locatedZone/Sub-City /Woreda Write Zone/Sub-City /Woreda name where the facility is located.Name of Health Facility Write the name of the health facility where the service was provided.Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Write the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)


1 S.N Sequential serial number in registration book; to be entered on client’s registration card for later identification in the register

2 MRN Write Medical record number3 Full Name Write full name of the adolescent or youth

4 Age (YY)/Sex ( M/F) Write the client age in years(YY) in the upper row , write the sex M= Male ;F=Fe-male in the lower row

5 Woreda/ Kebele Write Woreda in upper row and Kebele in the lower row

6 Gott/Ketena Write Gott or ketene 7 Marital status Write code M for married ; S for single ; D for divorced and W for widowed

8 Date of visit Write DD/MM/YY in Ethiopian calendar ; write with two digits of day, month and year

9 Comprehensive information and counseling on AYH Package ()

Tick () if comprehensive counseling and information on AYH standard of ser-vice package is given , this includes menstrual hygiene management, HIV/AIDS, pregnancy and CAC ,nutrition , etc

10 Referred from(write code)Write code 1. Self-referral 2. internal referral 3. Other facility

Note : internal referral is from OPD; Triage , One stop center, maternity (ANC, delivery ,PNC), CAC , Psychiatric of the facility .

HIV Testing

11 HIV testing accepted (√) Tick ( √) if the adolescent or youth accepts testing for HIV

12 HIV re-testing accepted (√) Tick ( √) if the adolescent or youth have already tested and know her/his status negative but risk for HIV

13 HIV test status ( P/ N) Write P in red pen if the test result is positive, write N in normal color if the result is negative.

14 Known HIV positives (linked from ART) (√) Tick ( √) if the adolescent or youth is known HIV positives and linked from ART


Write the code target population category listed below the register. an individual needs to be assigned only in one category that best describe him/her.

A. Female Commercial Sex workers

B. Long distance drivers

C. Mobile/Daily Laborers

D. Prisoners

E. OVC

F. Children of PLHIV

G. Partners of PLHIV

H. Other MARPS


Family Planning provided


Instruction for Integrated Adolescent and Youth Health Service Register

17 Repeat acceptor (√)Tick (√) if client is repeat acceptor at the time of registration. A repeat acceptor is someone who is not a new acceptor; in other words, a repeat acceptor has received a contraceptive method from a recognized Provide before registration.

18 Contraceptive Method provided

Write the abbreviate of Contraceptive method provided (record modern methods only) as follows:

MaC- Male Condom

FeC- Female Condom

OC- Oral Contraceptive

Inj- Injectable

EC- Emergency Contraception

Diaph-Diaphragm

IUCD- Intrauterine Contraceptive Device

Imp -Implant

L=link or refer

19 HCG(Pregnancy) test If HCG test provided write code P for positive ; N for negative and N/A if not applicable

Abortion care 20 Safe abortion care (√) Tick (√) if client provided with safe abortion care 21 Post abortion care(√) Tick(√) if client provided with post abortion care

22 STI syndromic approach diagnosis Write code 1. Virginal discharge; 2. Ureteral discharge; 3.Genital ulcer; 4.Lower Abdominal pain; 5.Scortale swelling 6.Ingunal bubo and 7. other specify)

23 Substance abuse

If the adolescent or youth use substance write code for

1. Alcohol use

2. Drug use

3. Tobacco/Smoking

4. Khat consume 5. Others

24 Psychotic problemWrite code 1. If Anxiety disorders; 2. Depression; 3. Psychosis; 4.Bipolar disor-der;5. Behavioral disorders; 6.other (specify) white N/A if not applicable

25 SGBV survivors Write Code for SGBV survivors if sustained 1 for physical violence 2. For psycho-logical violence 3. For sexual violence 4. For more than one violence (specify) 5. For all listed violence. N/A if not applicable

26 Non communicable illness screening

Write code 1. If BP taken for hypertension; 2. If fasting Blood sugar and urine sugar tested for DM; 3 asking if vaccinated for HPV ( age appropriate) ; If 4 Breast examination done or counselled for breast ca . 5. More than one done ( specify) 6. If all are done

27 Menstrual hygiene management /counselling and provision

Write 1. if counselled on menstrual hygiene management 2. If counselled and pro-vided material for menstrual hygiene

28 Refer/link to other service

If the adolescent and youth referred for service within the facility, write Code For internal linkage or referral 1. For maternity (ANC, Delivery, PNC) 2. For CAC 3. For FP 4. To one stop center (from SGBV) 5. Referred/ link to other facility

29 Providers name Write service providers name and signature

30 Remark If provided additional service like condom …); appointment date or any other concern

Personal Identification

Com

preh

ensi

ve in

form

atio

n an

d co

unse

l-lin

g on

AYH

Pac

kage

(√)

Refr

red

from

(wri

te co

de)

HIV testingFamily planning ( if Applicable)

HCG

( Pre

gnan

cy te

st)

resu

lt w

rite

(N/P

/NA

)

Abortion care

STI w

rite

code

Subt

ance

abu

se (w

rite

cod

e)

Psyc

hiat

ric p

robl

ems (

Wri

te co

de)

SGBV

surv

ivor

(Wri

te co

de)

Scre

ened

for n

on-c

omm

unic

able

dis

ease

s

Men

stur

al h

ygie

ne 1

= co

unse

lling

2. p

ro-

vide

d m

ater

ial

Refr

e to

oth

er se

rvic

e(w

rite

code

)

Prov

ider

’s na

me

and

sign

atur

e

Remark

S.N MRN Full NameAge

(YY)/ Sex (M/F)

Woreda /

Kebele

Got/ Ketena

Mar

ital s

tatu

s(W

rite

code

)

date

of v

isit(

DD/N

MM

/YY)

E.

C.

HIV

test

ing

acce

pted

(√)

HIV

re-te

stin

g ac

cept

ed (√

)

HIV

test

stat

us (

P/ N

)

Kno

wn

HIV

pos

itive

s lin

ked

from

ART

) (√)

Targ

eted

pop

ulat

ion

cate

gory

(w

rite

code

)

New

acc

epto

r (√)

Rep

eat a

ccep

tor (

√)

Con

trace

ptiv

e M

etho

d pr

ovid

ed

(Writ

e co

de)

Safe

abo

rtio

n ca

re (√

)

Post

abo

rtio

n ca

re(√

)

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 26 27 28 29 30

Count HIV Test CountR NR ND New Rep Safe abortion 10-14 Post abortion 10-14

Safe abortion 15-19 Post abortion 15-19



Marital Status col(7)S-singleW-WidowdD-DivorcedC-Cohabited

substance use Col(23)1.Alcohol use2. Drug use 3. Tobacco/Smoking 4. Khat consume 5. Other

Contraceptive Method Col(18)Mc=Male condom FeC=Female condom EP= Emergency pills OC=Oral contraceptive Inj=Injectabile IUCD= Intra uterine Device Imp=Implan Diaph-Diaphragm refer L=link or refer

Reffered from Col(10)1 .Youth Center 2. School 3 internal referral4. other facility

STI col(22)1. Viginal discahrge 2. Uretral discharge 3.Genital ulcure 4.Lower Abdomianl pain 5.Scortale swelling 6.Ingunal bubo 7. Other( specify)

None Communicable illnes: Col(26)1. BP for HPT 2.Blood and urine sugar for DM 3.Check if HPV vaccinated ( age appropriate) 4 Breast examination5. Other (Specify)6. All

Targeted population category col(15)A. Female Commercial Sex workers B. Long distance driversC. Mobile/Daily LaborersD. PrisonersE. OVCF. Children of PLHIVG. Partners of PLHIVH. Other MARPS I. General population

Psychotic Problem col(24) 1. Anxiety disorders; 2. Depression; 3. Psychosis; 4.Bipolar disorder;5. Behavioral disorders; 6.other (specify)

SGBV : Col(25)1.Physical 2. Psychological 3. Sexual 4. For more than one specify5. All6. NA

Refere to Other service Col(28)1.ANC,Delivery ,PNC2.CAC3.FP4. One Stop Center3.NCD Clinic4.Mental Clinic5.referred/Linked to other facility 6.Other specify

Integrated Adolescent and Youth Health Service Register


Health Centre /Clinic/Hospital GMP and <5 years Nutrition

Screening Register

Instruction for GMP and <5 years Children Acute malnutrition screening register


Region Write region name where the facility is locatedZone/Sub-City /Woreda Write Zone/Sub-City /Woreda name where the facility is located.Name of Health Facility Write the name of the health facility where the service was provided.Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Write the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)



2 MRN Write Medical record number3 Child full name Write full name of child4 Date of Birth Write the Child’s date of Birth, (DD,MM,YY)E.C

5 Age (MM)/Sex ( M/F) Write the exact age of the child in months(MM) in upper row and Child’s Sex: M=Male; F= Female in the lower row

6 Name of Mother/Care giver Write name of Mother. If not write care giver name7 Woreda/ Kebele Write Woreda in upper row and Kebele in the lower row8 Gott/Ketena Write Gott or ketene

9 PSNP beneficiary(Y/N) Write Y if is Child is of Productive Safety net program beneficiary(PSNP), If not Write N10 Growth Monitoring and Promotion ( GMP) for Under 2 years ( repeat this for all months)

Date of visit(Write day only) Write date of visit only in day (DD)Age( Month) Write age in monthWeight ( kg) Write weight in kilograms (kg)

Weight for age write code

( N, MU ,SU)

Write code for Weight for age Z-score result

N (Normal weight)= WFA>-2 Z score ,

MU (moderate underweight)= WFA between -3 and -2 Z score and

SU (Severe Underweight) = WFA <-3 Z score 11-34 Write date, age weight and classification in each visit column 35 Nutritional screening for < 5 years ( repeat this for all months)

Date of Visit( Day) Write date of visit only in day (DD)Age ( Month) Write age in month

Weight ( kg) Write weight in kilograms (kg)

Height/Length

Height or length in cm

N.B: Length in cm For children less than 2 years, or children too weak to stand

Height in cm for children 24-59 month or not weak to standMUAC( cm) Write the measurement of mid-upper arm circumference(MUAC) in cm after measuring left armBilateral Oedema (Y/N) Write Y If the child has bilateral pitting oedema when Checking, Write N if not .

Screening classification (N,MAM,SAM)

After children Under five years nutritionally screened , Classified accordingly

N (Normal )= if MUAC > 12.5cm or Z Score >-2 AND has no edema on both feet.

MAM (Moderate Acute Malnutrition)= If MUAC between 11.5 cm to <12.5 cm or WFL/H Z score inbe-tween-3 Z to < -2 and has no edema on both feet

SAM (Severe Acute Malnutrition) =If MUAC < 11.5 cm OR WFL/H < -3 , Z score or has edema on both feetDevelopmental milestone clas-sification(CDD,SDD,NDD)

write code Developmental Milestone Screening Status : CDD= Confirmed Developmental Delay ,SDD=Suspected Developmental Delay, NDD=No Developmental Delay

36-59 Write date, age, weight, Height/Length ,bilateral oedema and screening classification in each visit column60 Time and Age Appropriate Counseling Provided (TAAC)(repeat this for all month)

Date of visit( day) Write date of visit only in day (DD) Age( Month) write age in monthBreastfeeding Tick✓ if Counselling provided on Breast Feeding Initiation of Complementary feeding Tick ✓ if Counselling provided on initiation of complementary feeding

Feeding of Sick child Tick✓ if Counseling provided on feeding of sick child Counsel on care for develop-mental milestone Tick ✓ if Counseling provided on care for Developmental Milestone

61-72 Write date, age and Tick✓ if Counselling provided on Breast Feeding, complementary feeding of sick child, and care for dev’tal milestone

73 Action(Write code)write code for action taken as follows

Action:1. Referral 2.OTP,3. SC 4.TSFP 5.PSNP 6.Other (specify)


PSN

P be

nifi-

cary

(Y/N

)

GMP

GMP for Under 2 YearsNutrition Screening and

Developmental milestone assessment U5

Nutrition Screening for under 5 years

Time and Age Approprite Councelling Provided (TAAC)


Action(Write code)S.N MRN Child full Name

Date of Birth (DD,MM,YY)

Age(MM)/

Sex (M/F)

Name of the mother /caregiver

Woreda/ Kebele

Got/ Ketena

Year 1 Year 2 Year 1 Year 2

Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb SenHam Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73

1

Date of visit ( Write day only)



Age(Month) Age(Month) Age(Month)

Weight(kg)

Weight (kg) Breast feeding

Height/Lengeth (cm)

MUAC( cm) Initiation of Complementary feeding

Weight for Age write code (N, MU, SU)

Bilateral Oedema (Y/N)

Feeding of sick childScreening classification (N,MAM,SAM)

Developmental milestone classifcation(ND,SD,DD)

Care for child development (CCD)

1





Weight(kg)


Height/Lengeth (cm)




Feeding of sick childScreening classifica-tion(N,MAM,SAM)







Weight(kg)


Height/Lengeth (cm)







Count Count

Normal(N) Normal(N)

Moderate(MU) MAM

Sever(SU) SAM

Total ND

SD

DD

GMP and <5 years Nutrition Screening Register

CodingGMP underweight classification N= normal weight, MU= Moderate underweight SU= se-vere underweight Screening classification N= Normal, MAM= Moderate Acute Malnutrition, SAM =Severe Acute MalnutritionComplementary feeding DD= dietary diversity, FF= Food frequency, FC= Food consistencyAction Taken :1. Referal 2.OTP,3. SC 4.TSFP 5.PSNP 6.Other (specify)

Year ____________________


PSN

P be

nifi-

cary

(Y/N

)

GMP

GMP for Under 2 YearsNutrition Screening and

Developmental milestone assessment U5

Nutrition Screening for under 5 years



Action(Write code)S.N MRN Child full Name

Date of Birth (DD,MM,YY)

Age(MM)/

Sex (M/F)

Name of the mother /caregiver

Woreda/ Kebele

Got/ Ketena

Year 1 Year 2 Year 1 Year 2

Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb SenHam Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen Ham Neh Mesk Tik Hid Thah Tir Yek Meg Miyaz Ginb Sen

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 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73

1





Weight(kg)


Height/Lengeth (cm)




Feeding of sick childScreening classification (N,MAM,SAM)



1





Weight(kg)


Height/Lengeth (cm)











Weight(kg)


Height/Lengeth (cm)







Count Count

Normal(N) Normal(N)

Moderate(MU) MAM

Sever(SU) SAM

Total ND

SD

DD

GMP and <5 years Nutrition Screening Register

Action (Write code):731. Referral 2.OTP,3. SC 4.TSFP 5.PSNP 6.Other (specify)

0-24m25-59m

0-24m25-59m

0-24m25-59m

Year ____________________


Health Centre /Clinic/Hospital Therapeutic Feeding Program

Register

Instruction for Therapeutic Feeding RegistrationLocation information to be completed at front of the registry

Region Write the region where the facility is locatedWoreda / Sub-City Write the woreda/sub-city where the facility is located.Name of Health Facility Write the name of the health facility where the PNC was provided.Register begin date Enter the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register end date Enter the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Col N Data elements Description

1 Serial number Write sequential serial number in the registration book

2 Unique SAM NOWrite unique SAM number for each child during registration when she/he is first admitted to outpatient care or inpatient care to overcome the problems of confusing registration use 3- digit numbering system

3 MRN write the Medical Record Number (MRN)

4 Full name of child Write full name of children

5 Name of care giver Write full name of care giver

6 Woreda Write the woreda


8 Gott Write the Gott

9 Age( Month) Write age of child in month

10 Sex ( M/F) Write M for Male or F for Female

11 New admission(Y/ N) Write Y = New Admission , N or if not

12 Transfer In or re-admission(T/R) Write T for Transfer In or R for readmission 13 Date ( DD/ YY/MM) Write Date of admission as DD/ MM/YY (EC)

14 Weight( Kg) write weigh in kg at admission

15 Height ( cm) Write height in cm at admission

16 WFH % Write weight –for-height percentage depending on anthropometric finding and WFH reference

17 Oedema(0,+,++,+++)

Write 0= Absent bilateral pitting Oedema+= grade + ( Mild :Both feet/ankles bilateral pitting Oedema)++= Grade ++ ( Moderate :Both feet ,plus legs, hands or lower arms)+++= Grade ++(Severe : generalized bilateral pitting oedema, including both feet, legs, arms and face)after checking bilateral Oedema

18 MUAC( cm) Write value of Mid-Upper Arm Circumference(MUAC) in cm

19 Diagnosis write code Write code MA= Marasmus or KA=Kwashiorkor orBO= both( if Diagnosis is marasmus and Kwashiork)

20 Date( DD/MM/YY) Write discharge date as ( DD/ MM/YY)

21 Weight( Kg) write discharge weight in kg

22 Height( cm) Write height measurement in cm

23 WFH% Write weight –for-height percentage value depending on anthropometric finding and WFH reference

24 Oedema(0,+,++,+++)

Write 0= Absent bilateral pitting Oedema+= grade + ( Mild :Both feet/ankles bilateral pitting Oedema)++= Grade ++ ( Moderate :Both feet ,plus legs, hands or lower arms)+++= Grade ++(Severe : generalized bilateral pitting oedema, including both feet, legs, arms and face)after checking bilateral pitting Oedema during discharge

25 MUAC( cm) Write value of Mid-Upper Arm Circumference(MUAC) in cm during discharge

26 Minimum Weight(Kg) Write Minimum weight in kg during stay of OTP or SC

27 Date of Minimum Weight(DD/MM/YY) Write (DD/MM/YY) of Minimum weight at OTP or SC

28 Length of stay Put total number of days between admission and discharge for cured non edematous children at OTP or SC

29 Outcome

Write code for treatment outcomes1. Recovered(Cured): child that has reached the discharge 2. Died = Patient that has died while he was in the programme. For out-patient programme, the death has to be con-

firmed by a home visit3. Unknown: Patient that has left the programme but his outcome (actual defaulting or death) is not confirmed/ ver-

ified by a home visit4. Defaulter: Patient that is absent for 2 consecutive weighing (2 days in in-patient and 2 weeks in out-patient), con-

firmed by a home visit5. Non-responder:Patient that has not reached the discharge criteria after 40 days in the in-patient programme or 2

months in the out-patient programme6. Medical transfer: Patient that is referred to a health facility/ hospital for medical reasons and this health facility will

not continue the nutritional treatment7. Transfer Out :Patient that has started the nutritional therapeutic treatment in your programme and is referred to

another site to continue the treatment

30 Remark Write any note the provider want to document


New

Adm

issi

on(Y

/N)

Tran

sfer

-in o

r re

-adm

is-

sion

(T/R

)

Admission DischargeMinimum

weight for non oedematous

children Recov-ered

Leng

th o

f Sta

y (d

ay)

Outcome (Recovered, died , Unknown, default-

ed, non-respondent, medical transfer and

transfer out)

RemarkSN Unique

SAM # MRN Full name of child Full name of caregiver

Address

Age (Month)

Sex ( M/F)Woreda Kebele Gote Date

(dd/mm/yy)

Wei

ght(

Kg)

Hei

ght(

cm)

WFH

%

Oed

ema(

0,+,

++,+

++)

MU

AC(c

m)

Dia

gnos

is (M

aras

-m

us,K

asho

rkor

,Bot

h)

Dat

e(dd

/mm

/yy)

Wei

ght(

Kg)

Hei

ght(

cm)

WFH

% o

r BM

I

Oed

ema(

0,+,

++,+

++)

MU

AC(c

m)

Min

imum

W

eigh

t(Kg

)

Dat

e of

Min

i-m

um W

eigh

t

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 26 27 28 29 30

Count Count

WFH

<70

Oed

ema

MU

AC <

11 Recovered

Died

Unknown

Defaulted

Non-respondent

Medical transfer

Transfer out

Therapeutic Feeding Register

Count


Health Centre /Clinic/Hospital Pregnant and Lactating Women (PLW)

Nutrition screening Register

Col.No Data Elements Description

1 S.N Write sequential serial number in the registration book

2 MRN Write Medical record number

3 Full Name Write full name of Pregnant or lactating women

4 Age Writer age of the woman in years

5 Woreda Write the name of woreda

6 Kebele Write the name of kebele

7 Gott/ketena Write the Gott/ ketena

8 Status( P/L) Write P if she is pregnant or L if she is lactation women with < 6 months children

9 PSNP beneficiary (Y/N)

Write Y if she is Productive Safety Net Program( PSNP) Beneficiary or N if she is not beneficiary

10-22 PLW Nutritional Screening(will be repeated for all months)

Date of Visit ( DD) Write date of visit (day only( DD))

Weight Write weight in kilogram(Kg)

MUAC Write Mid Upper Arm Circumference (MUAC) in cm

Malnourished (Y/N) Write Y if MUAC < 23 cm or N if MUAC > 23 cm

Nutrition Counsel-ing(✓) (1,2,3,4,5,6)

Tick ✓ If all the following listed nutritional Counseling is provided:1. For Pregnant women eat One extra meal every day2. For lactating women eat two extra meal every day3. Eat variety & diversified food4. Deworming at 2nd or third trimester (pregnant women only)5. IFA every day minimum at least 90 days plus6. Sleep under insecticide treated net

Action (A, B, C, D)

Write the codeA. Counseling providedB. Referred to TSFPC. Referred to PSNPD. Referred to other (specify)

Instruction for Pregnant and Lactating Women

(PLW) Nutritional Screening Register


Region Write the region where the facility is locatedWoreda / Sub-City Write the woreda/sub-city where the facility is located.

Name of Health Facility Write the name of the health facility where the PNC was provided.

Register begin dateEnter the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register end date Enter the date of the last entry in the register, written as (EC) Day / Month / Year( DD/MM/YY)

Pregnant and Lactating Women (PLW) Nutrition screening Register Pregnant and Lactating Women (PLW) Nutrition screening Register

SN MRN

Peersonal Identification PSNP benifi-

cary (Y/N)

Pregnant and Lactating Women (PLW) screening

Full Name Age Woreda Kebele Gott / Ketena

Sta-tus

(P/L) Screening Ham Neh Mes Tik Hid Thas Tir Yek Meg Miaz Ginb Sen

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22Date of visit (Write day DDWeight (kg)MUAC (cm)Malnourished (Y/N)If all Nutrition Counseling Provided(✓) (1,2,3,4,5,6)Action (A,B,C,D)Date of visit (Write day DDWeight (kg)MUAC (cm)Malnourished (Y/N)If all Nutrition Counseling Provided(✓) (1,2,3,4,5,6)Action (A,B,C,D)Date of visit (Write day DDWeight (kg)MUAC (cm)Malnourished (Y/N)If all Nutrition Counseling Provided(✓) (1,2,3,4,5,6)Action (A,B,C,D)Date of visit (Write day DDWeight (kg)MUAC (cm)Malnourished (Y/N)If all Nutrition Counseling Provided(✓) (1,2,3,4,5,6)Action (A,B,C,D)Date of visit (Write day DDWeight (kg)MUAC (cm)Malnourished (Y/N)If all Nutrition Counseling Provided(✓) (1,2,3,4,5,6)Action (A,B,C,D)CountMUAC<23 cmMUAC>=23cmTotal screenedNumber of referal to TSFP Counseling provided

Nutrition counseling (NC) codes1. For Pregnant women eat One extra meal every day2. For lactating women eat two extra meal every day3. Eat variety & diversied food4.Deworming at 2nd or third trimester (pregnant women only)5.IFA every day minimum atleast 90 days plus6.Sleep under insecticide treated net

Action codes A. Counseling providedB. referral to TSFPC. referal to PSNPD. referal other (specify)


Health Centre /Clinic/Hospital MAM treatment for 6-59 months

The registration book for MAM is used in TSFP. The data is aggregated at the end of each month and used to pre-pare the Monthly Statistics Report for MAM.

Information on the Front Cover of the Registration BookData element Description

Region: Write the Region name of where the health facility is located.

Zone: Write the Zone name of where the health facility is located.

Woreda: Write the Woreda name of where the health facility is located.

Kebele: Write the Kebele name of where the health facility is located.

Health Facility: Write the name of the health facility where the service is provided.

Register Start Date: Write the date of the first entry in the register, written as (EC) Day/Month/Year (DD/MM/YY).

Register End Date: Write the date of the last entry in the register, written as (EC) Day/Month/Year (DD/MM/YY).

S.No Background Information

1 Serial Number Write sequential registration numbers. The registration number is issued when the patient is admitted, it includes a service code indicating where rehabilitation was initiated TSFP.

2 MRN Write the patient’s Medical Record Number (MRN).

3 Full Name of the child Write the full name of the patient.

4 Kebele: Write the Kebele name of where the child resides.

5 Gote/village Write the Gott or Village where the child resides.

6 Sex Write F for female or M for male.

7 Age Write the age of the child in months.

8 New Admission Write Y if a new admission and N if not. [A new admission is a new case who meets the admis-sion criteria for TSFP.

9 Relapse Write Y if a Relapse and N if not. Relapse is a patient who cured within the past 3 months and now meets the admission criteria for TSFP .

10 Returned default Write Y if returned default and N if not Child who defulted within the past 3 months and has returned to continue treatment in TSFP.

11Transfer-in from other facili-ty, TSFP

Write Y if transfer-in and N if not. has moved in from another facility where they were receiv-ing TSFP.

Admission/Entry Information12 Admission Date Write the date of admission to service, written as (EC) Day/Month/Year (DD/MM/YY).

13 MUAC Write the MUAC measurement value in cm.

14 Albendazole/Mebendazole Write y if the child received Albendazole/Mebendazole N if not

15 Weight Write the weight measurement value in kg.

16 Height/Length (cm) Write the height measurement value in cm.

17 WFH/L (Z-Score) Write the WFH/WFL value in z-score in reference chart.

Discharge/Exit Information18 Discharge Date Write the date of discharge from service, written as (EC) Day/Month/Year (DD/MM/YY).


20 Weight Write the weight measurement value in kg.

21 Height Write the height measurement value in cm.

22 WFH/L(Z Score) Write the WFH/WFL value in z-score.

23 Outcome

Write the code for the treatment outcome: C = Cured: Has reached the discharge criteria of TSFP. D = Died: Dies while receiving treatment in the TSFP. DF = Defaulted: Absent for two consecutive visits in TSFP. Default should be confirmed. NR = Non-responder: Does not reach the TSFP discharge criteria after 16 weeks (4 months). T = Transfer out: Condition has deteriorated or not responding to treatment and referred for treatment in the OTP/SC, moved out to receive treatment in another TSFP.

24Counseled on Care for Child Development/CCD (Y/N) Write Y if the client is counseled on care for Child Development, otherwise N

25 Remark Write any notes the service provider wants to document.

Instructions on How to Complete the Registration Book for MAM for 6-59 months.


New

Adm

issi

on(Y

/N)

rela

pse

( Y/N

)

Retu

rned

def

ault

(Y/N

)

Tran

sfer

-in fr

om o

ther

TSF

P (Y

/N)

Admission/ Entry Information Discharge/Exit Inormation

RemarkSN MRN Full name

Adress

Sex

(M/F

)

Age(

mon

ths)

Kebe

le

Got

e/Vi

llage

Date (dd/mm/

yy)

Bila

tera

l Pitti

ng O

de-

ma

(writ

e N

= N

o ,

+=M

ild,+

+=M

oder

-at

e,++

+=Se

vere

)

MUA

C(cm

)

Wei

ght (

kg)

Albenda-zole/Me-benda-

zole(Y/N)

Heig

ht/L

engt

h (c

m)

WFH

/L (Z

-Sco

re)

Date

(dd/

mm

/yy)

MUA

C(cm

)

Wei

ght(

Kg)

Heig

ht(c

m)

WFH

/L(Z

Sco

re)

Out

com

e (C

ured

, die

d ,

defa

ulte

d, n

on-r

espo

n-de

nt, a

nd tr

ansf

er o

ut)

Coun

sele

d on

Car

e fo

r Ch

ild D

evel

opm

ent/

CCD

(Y/N

)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 15 16 17 18 19 20 21 22 23 24 25

Count of Discharge Outcomes.

Cured

Died

Defaulted

Non-responder

Transfer-out

Registration Book for MAM treatment for 6-59 months


Health Centre /Clinic/Hospital MAM treatment for Pregnant and

lactating women Register

The registration book for MAM is used in TSFP. The data is aggregated at the end of each month and used to prepare the Monthly Statistics Report for MAM.

Information on the Front Cover of the Registration BookData element Description

Region: Write the Region name of where the health facility is located.

Zone: Write the Zone name of where the health facility is located.

Woreda: Write the Woreda name of where the health facility is located.

Kebele: Write the Kebele name of where the health facility is located.

Health Facility: Write the name of the health facility where the service is provided.

Register Start Date: Write the date of the first entry in the register, written as (EC) Day/Month/Year (DD/MM/YY).

Register End Date: Write the date of the last entry in the register, written as (EC) Day/Month/Year (DD/MM/YY).

Background Information

1 Serial Number Write sequential registration numbers. The registration number is issued when the patient is admitted; it includes a service code indicating where treatment was initiated.

2 MRN Write the patient’s Medical Record Number (MRN).3 Full Name Write the full name of the patient.

4 Age Write the age of the PLW.

5 EDD Expected date of delivery

6 Kebele Write the Kebele name of where the patient resides.7 Gote/village Write the Gott or Village where the patient resides.

8 New Admission Write Y if a new admission and N if not. [A new admission is a new case who meets the ad-mission criteria for TSFP.

9 Relapse Write Y if a relapse N if not. Relapse is a patient who cured within the past 3 months and now meets the admission criteria for TSFP

10Relapse /return default)

Write Y if a returned default and N if not [When patient who defulted within the past 3 months and has returned to continue treatment in TSFP.

11Transfer-in from other TSFP

Write Y if transfer-in and N if not. has moved in from another facility where they were receiv-ing TSFP.

Admission/Entry Information

12 Admission Date Write the date of admission to service, written as (EC) Day/Month/Year (DD/MM/YY).


14Albendazole/ Mebendazole Write yes if the Albendazole/ Mebendazole was given and N if not.

Discharge/Exit Information

15 Discharge Date Write the date of discharge from service, written as (EC) Day/Month/Year (DD/MM/YY).


17 Outcome

Write the code for the treatment outcome:

C = Cured: Has reached the discharge criteria for SAM treatment. D = Died: Dies while receiving treatment in the TSFP. DF = Defaulted: Absent for two consecutive visits in TSFP.

NR = Non-responder: Does not reach the MAM discharge criteria after 16 weeks (4 months) in treatment - TSFP. T = Transfer out: Moved out to receive TSFP in another facility.

18 Remark Write any notes the service provider wants to document.

Instructions on How to Complete the Registration Book for MAM PLW.


New Admission

(Y/N)

relapse ( Y/N)

Re-turned default (Y/N)

Trans-fer-in from other TSFP (Y/N)

Admission/ Entry Information Discharge/Exit Inormation

RemarkSN MRN Full name Age

Expected date of delivery

(EDD)

Adress

Kebele Gote/Village

Date (dd/mm/

yy)

MUAC (cm)

Albendazole/ Mebenda-zole(Y/N)

Date (dd/

mm/yy)

MUAC (cm)

Outcome (Cured, died , defaulted,

non-respondent, and transfer out)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Count of Discharge Outcomes. (Col.17)Cured

Died

Defaulted

Non-responder

Transfer-out

Registration Book for MAM treatment for PLW


Health Centre /Clinic/Hospital Vitamin A Supplementation and Deworming

Register








2 MRN Write Medical record number

3 Child full name Write full name of child

4 Age (MM)/Sex ( M/F) Write the Child’s Sex “M” if Male ; and “F” if Female

5 Date of Birth Write the Child’s date of Birth, (DD,MM,YY)E.C

6 Name of Mother/Care giver Write name of Mother. If not write care giver name

7 Woreda/ Kebele Write Woreda in upper row and Kebele in the lower row

8 Gott/Ketena Write Gott or ketene

9 Age of the child (in months) on date of registration Write the age of child in month (6-59mos) at the date of service provision

Year (YYYY): Write the year in “YYYY” format.

10,14,18,22, and 26 Dose_1(DD/MM/YY) Write Vitamin A Dose1 revived date month and year like (DD/MM/YY) in Ethiopian calendar year

11,15,19,23, and 27 Dose_2(DD/MM/YY) Write Vitamin A Dose2 revived date month and year like (DD/MM/YY) in Ethiopian calendar year

12,16,20,24, and 28 Dose_1(DD/MM/YY) Write deworming Dose1 revived date month and year like (DD/MM/YY) in Ethiopian calendar year

13,17,21,25, and 29 Dose_2(DD/MM/YY) Write deworming Dose2 revived date month and year like (DD/MM/YY) in Ethiopian calendar year

Instruction for Routine VAS and Deworming register


S.N

Demographic Information AddressAge of the

child (in months) on

date of regis-tration

Year (YYYY):______________ Year (YYYY):______________ Year (YYYY):______________ Year (YYYY):______________ Year (YYYY):______________

MRN Child full NameSex

(M/F)

Date of Birth (DOB)

Name of the mother/caregiver

Woreda/ Kebele

Got/Ketena /House

No.

VAS Deworming VAS Deworming VAS Deworming VAS Deworming VAS Deworming

Dose_I (DD/MM/YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/

YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/YY)

Dose_2 (DD/MM/YY)

Dose_I (DD/MM/

YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/

YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/

YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/

YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/

YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/YY)

Dose_2 (DD/MM/

YY)

Dose_I (DD/MM/YY)

Dose_2 (DD/MM/YY)

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 26 27 28 29

ROUTINE VITAMIN A SUPPLEMENTATION AND DEWORMING REGISTRATION BOOK


Health Centre /Clinic/Hospital Abortion Care Tally Sheet

Abortion Care Tally SheetWoreda:__________________________Year:__________________

Facility: _______________ Month:__________________

Age Category

Safe abortion Post abortion careTotal count

10-14 Years 15-19 years 20-24 years 25-29 years + 30 years 10-14 Years 15-19 years 20-24 years 25-29 years + 30 years

First trimester

(<12 week)

Tally

Count

Second trimester

(>=12 weeks)

Tally

Count

Total


Health Centre /Clinic/Hospital Adolescent nutrition Service Tally

Adolescent Nutrition Service TallyWoreda ________ Health facility____________ Year______________ Month_______________

Service

Male FemaleTotal count 10-14 15-19 10-14 15-19

Tally Count Tally Count Tally Count Tally Count

Nutritional screeing

Nornal

Under weight

Overweight

Obese

Very obese

Total count

Deworming

Dose 1

Dose 2

Total count

Iron Folic acid(IFA)

Adolsecent received IFA tablets for four conscuative weeks in the reporting period


Health Centre /Clinic/Hospital ANC Tally Sheet

ANC Tally SheetWoreda:__________________________ Year:__________________

Facility: _______________ Month:__________________

Service Tally

GA 10 -14 years Count 15 - 19 years Count >20 years Count Total count

ANC First Contact

<12 weeks

12 to 16 weeks

>16 weeks

Total count

ANC Fourth (4th) Contact

<30 Weeks

30 Weeks

> 30 Weeks

ANC Eighth (8th) Contact

Women recived Iron(IFA) 90+

Pregnant Women Dewormed

Syphilis Screening

Reactive

Non reactive

Total tested (count)

Reactive treated syphilis

Hepatities

Reactive

Non reactive

Total tested (count)

Total No. of Reactive pregnant women provided prophylaxis

Reactive Treated for Hepatitis


Health Centre /Clinic/Hospital Comprehensive and Integrated Nutrition Service

for <5 years Tally Sheet

Woreda:__________________________ Facility: _______________ Year:__________________ Month:__________________

GMPWeighted during GMP

0-5 months 6--23 MonthsTotal CountTally Count Tally Count

Z score >= -2(Normal)

Z score between -3 and -2 (moderate under weight)

Z score < -3(Sever under weight)

Total count

Nutritional ScreeningNutritional Screening for under 5 year

0-5 months 6 - 23 Months 24 - 59 MonthsTotal countTally Count Tally Count Count

Normal

Moderate Acute Malinutrition(MAM)

Sever Acute Malinutrition (SAM)

Total screened for Malinutrition(Count)

Vitamin A Vitamin A 6-11 months 12-59 months Total Count

Vitamin A One doses suplimented Vitamin A Two doses suplimented

Deworming (24-59 months)Deworming (24-59 month) Tally Count Received one dose Received two doses

Developmental milestone0-23 months 24-59 months Total Count

Tally Count Tally CountConfrimed developmental delay(CDD)Suspected developmental delay(SDD)No developmental delay(NDD)

Comprehensive and Integrated Nutrition Service for <5 years Children tally sheet


Health Centre /Clinic/Hospital Family Planning Dispensing Tally

Woreda:___________________ Health Post:________________ Year:__________________

MonthsMale Condoms

2. Oral contraceptives 3. Injectable (Depo provera) 4. Implanon

Female Condoms

Number issued Count Number of monthly cycles distributed Count Number of injections given Count Number of Implanon insertions Count

Hamle

Nehase

Meskerem

Tikmpt

Hidar

Tehsas

Tir

Yekattit

Megabit

Miazia

Ginbot

Sene

Total

Family Planning Dispensing Tally


Health Centre /Clinic/Hospital Family Planning Service Tally

Woreda:__________________________ Facility: _______________ Department: _______________ Year:__________________ Month:__________________ MOH V12013

Methods 10-14 years 15-19 years 20 - 24 years 25 -29 years 30-49 yearsTally Count Tally Count Tally Count Tally Count Tally Count

New acceptors

Oral Ccontraceptives

Injectables

Implants

IUD

Vasectomy

Tubaligation

Other

Repeat acceptors

Oral Contraceptives

Injectables

Implants

IUD

Vasectomy

Tubaligation

Other

Family Planning Service Tally


Health Centre /Clinic/Hospital PMTCT Tally Sheet

Woreda:__________________ Facility: _______________ Department: __________________

Year:__________________ Month:__________________

ServiceNewly diagnosed & started on ART Count

Known HIV +On ART at entry Count Not on ART Count

HIV +ve mother enrolled to ART

ANC

Delivery

PNC

Service Positive NegativeTotal count

Infants received DNA/ PCR test Result

Within 2 MonthTally Count Tally Count

Between 2 - 12 months

total with in 12 months

Infants who received ARV prophylaxis for 12 weeksfor 12 weeks Count Total count

Infants receiving HIV confirmatory (antibody test) by 18 months

Positive Count Negative Count Total count

Infants started on cotrimoxazole prophylaxis within 2 months

Service 10-14 years 15 - 19 years 20 - 24 years 25 - 49 year Total countTally Count Tally Count Tally Count Tally Count

TB Screening for HIV

Screened for TB

Screened Positive

Active TB

TB treated

HIV positive woman received INH prophylaxis

Viral load Total tested

Undetectable (<1000 copies )

Family planning Acceptors

Short acting

long acting

Nutritional screen-ing

NormalMildMAMSAMReceived TSF

PMTCT Tally Sheet


Health Centre /Clinic/Hospital Pregnancy Test Tally Sheet

Woreda:__________________________ Facility: _______________ Year:__________________ Month:__________________

Description10-14 years 15-19 years ≥20 years

TotalTally Count Tally Count Tally Count

Women tested

HCG postive

Pregnancy Test Tally Sheet


Health Centre /Clinic/Hospital Routine Immunization Tally Sheet

Woreda:__________________________ Facility: _______________

Year:__________________ Month:__________________

Type of session: □ static □ Outreach □ Mobile

ANTIGENUnder 1 year Childrens’ One year and older Childrens’

TotalTally Count Tally Count

BCG

HepBHepB BD within 24 Hrs

HepB BD after 24 Hrs-14 days

Pentavalent

Pentavalent 1

Pentavalent 2

Pentavalent 3

OPV

OPV 1

OPV 2

OPV 3

IPVIPV1

IPV2

PCV

PCV 1

PCV 2

PCV 3

RotaRota 1

Rota 2

Measles

Measles 1 (MCV1)

Meseals 2 (MCV2)

Fully immunized

Protected at Birth from NNT (PAB)

Td all doses given (Td1-Td5)

Doses Tally Count

Td1

Td 2

Td 3

Td 4

Td 5

Routine Immunization Tally Sheet

TB and leprosy RegistersContent / Home

Health Centre/Clinic/Hospital DR TB Follow up Register


SN Variable Description

1 MDR TB reg. Number Refering Health facility

Upper space: Write a new unique patient identification number assigned by treatment initiating center. The DRTB unique number is assigned as:Region/Type of facility/facility code/five digit serial number with DR prefix.For instance, If a patient is started on SLD treatment at St peter hospital and is the 22nd patient to be put on SLD at the center.His/her unique DR number will be: 14/08/020/DR00022Lower space: Write name of the health facility initiating the DR TB treatment

2 Patient Name & AddressUpper space: Write patient name, father and grandfather nameLower space:full address of the patient including telephone Number

3Sex Upper Space: Enter M= Male and F= FemaleAge Middle Space: Enter age of patient as indicated in DR TB treatment cardHeight(cm) Lower Space: Write the patient’s height in centimeters (NB: To be used to calculate BMI column #8)

4 Contact person name & addressUpper space: Write contact person name, father and grandfather nameLower space:full address of the contact person including telephone Number

5 EligibilityEnter the type regimen prescibed to DR TB patients in the space provided as follow: Enter “1” if the patient is eligible for Short term DR anti TB regimen ; “2” if the patient is eligible for long term regimen ; Enter “3” if the patient is eligible for individualized long term anti TB regimen,”4” Hr-TB regimen

6

Registration group Upper space:There are seven possible options to choose. Select only one and enter the code as follow1. New 2. Relapse 3. Treatment After Lost to follow up 4. After failure of treatment regimen with FLD 5. After failure of treatment regimen with SLD 6. Transfer in from another DR TB Initiating center 7. Other, Specify and write the registration group in the remark if it is different from the list

Site Middle space:Enter the site of TB: “Pul” for pulmonary and EP for extra-pulmonary NB: Patients with both pulmonary and extra pulmonary TB should be classified as a case of pulmonary TB.

Resistant type Lower Space: Write Hr-TB for INH resistance , “RR” for Rifampicin-resistant, “M” for MDR ; “PX” for Pre-XDR;“X” for XDR; and “PR” for Poly-resistant

7 weight monitoring Write weight of the patient in space provided at monthly base; copy all weight monitored at the treatment center from the treatment card of the partient in to the registartion and continue montoring of patient weight at your facility for intensive & continuation phases.

8 BMICalculate BMI and Enter the value. BMI is computed as weight in kg divided by height in meter square. For patient age 5-18 years, use BMI-for-age and refer standard charts. Measure and enter MUAC in cm for pregnant, bedridden or under-five patient

9 Intensive Phase:Drugs Enter each drug abbreviations being used in the intensive phase 10 Intensive Phase:Dose Enter the dose of each drug during the intensive phase.11 Treatment started write the date treatment started as(EC); Day/Month/Year (DD/MM/YY)

(12,13) Intensive Phase: Smear & culture result

Record all smear and culture results specific to the month on treatment. If more than one smear or culture done in a month, enter the most recent result. Use the following abbreivation in the space provided: Enter “P” for positive result using red pen; “N” for negative results and “U” for results not available/not done

14 Write the month Write the name of the month(eg:- Tikimit, Hidar..) for each month of intensive treatment until the patient finished his/her treatment.

(15-44) Treatment monitoring: Intensive phase

This part is used to record daily drugs administered/taken by the patient during the intensive phase; one box is checked for each day the treatment administered. For instance if the patient has morning and evening doses, divide the box in to two part and use in the upper portion to check for morning doses and the lower portion for evening does. Write “3” for directly observed; “2” for not observed;”1” drug not taken/missed does.

45 Continuation Phase:Drugs Enter the initial of each DR TB regimen being used by individual patient in the continuation phase.

46 Continuation Phase:Dose Enter dose in milligram of each DR TB regimen being used by the individual patient during in the continuation phase.

INSTRUCTION FOR DR TB REGISTRATION AT TREATMENT FOLLOW UP HEALTH FACILITIES

Register (HC/Clinic/Hospital-TB DOTs Reg.) kept in drug resistant ( DR) TB/TB-DOTS room, and completed by the TB care provider.


Region Write the region where the DR TB-Treatment initiating center is located

Woreda / Sub-City Write the woreda/sub-city where the DR TB-Treatment initiating center is located.

Name of Health Facility Write the name of the health facility where the DR TB-Treatment initiating center is located.

Register Begin Date Enter the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register End Date Enter the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

47 weight monitoring Write weight of the patient in space provided at monthly base; copy all weight monitored at the treatment center from the treatment card of the partient in to the registartion and continue montoring of patient weight at your facility for intensive & continuation phases.

48 BMICalculate body mass index (BMI) of the patient’s monthly using the following formula (Bodyweight in kilograms divided by height in meters squared)and write on the space provided and also manage Under nourished patients according to the national program guideline.

(49,50) Continuation Phase: Smear & culture result

Record all smear and culture results specific to the month on treatment. If more than one smear or culture done in a month, enter the most recent result. Use the following abbreivation in the space provided: Enter “P” for positive result using red pen; “N” for negative results and “U” for results not available/not done

(51-62) Treatment monitoring: continuation phase

Enter the days in the rows for the monthly column when the patient attended for treatment montoring during the continuation period of treatment.

(63-65) TB/HIV activities Enter Testing results if the patient tested for HIV. Enter R in red pen if test is reactive; NR in normal color of pen if test is not reactive or I in normal color of pen if test is indeterminate.

(66-67) Adverse effect Upper Space: Enter the initial of suspect DR TB drugLower Space: Write the side effect observed and the action taken for the adverse in the next column

68

Upper Space: Total Household and/or close contacts of index cases.

Upper space: Enter total number Household contacts

Middle space: Total number of contacts screened for TB Middle space: Enter number of HH contacts screened for TB/ DR-TB at HF

Lower space: TB Diagnosed among Contacts Lower space: Enter number of TB/DR TB cases diagnosed among contact of index DR TB cases

69

Upper Space: Total under 15 years HH and/or Close Contacts including under 5

Upper space: Write total number of Household and/ or close contacts including under 15 years old

Middle space: Total under 15 years contacts and/or Close contact Screened for TB

Middle space: Enter number of under five children Household and/ or close contacts screened for TB /DR-TB at HF

Lower space: Total under 15 HH and/or Close contact free from TB and put on IPT

Lower space: Enter number of Under 15 years TB/DR TB Diagnosed among Contacts of Index DR TB cases NB: all contacts with no active TB at time of evaluation should continue to receive careful clinical follow-up quarterly for a period of at least two years and should be recorded regulary.

70 Nutritional Assessment : Classification

Interpret the anthropometry and enter the nutritional assessment result as follow : : If normal, write “N”; ; if moderately undernourished, write “MAM”. If severely undernourished, write “SAM” SAM criteria in Adults:-( BMI <16 OR MUAC <18cm;for pregnant women and lactating mothers MUAC <19 cm OR edema of both feet without clear cut other cause) MAM criteria in Adults:- ( BMI 16 - <17.5 OR MUAC 18 - <21 cm; For pregnant women and lactating mothers: MUAC 19- <23 cm OR; For HIV positive client: Confirmed (>5% weight loss since last visit) or reported weight loss (e.g. loose clothing) AND No edema of both feet

71 Nutritional Management

Write Nutritional Management given for patient in the space provided:- If no intervention and only nutritional advices is provided enter “1” ; if the patients has given supplementary food enter ”2”; and if patient is on Therapeutic Management enter ”3” NB: For DR-TB cases, those with severely undernourished (SAM) cases will receive the Ready -To-Use Therapeutic food(RUTF) and those with moderately undernourished (MAM) cases receive Supplementary food(RUSF) based on availability of supplies.

72 Nutritional treatment: Outcome

Upper space: Record the final outcome of the therapeutic or supplementary food treatment as: recovered/cured ; No change; other outcome(specify) NB: The following arithmetic measure should be consider to label patients as recovered/cured from nutrition related problem, if Adult (non-pregnant/lactating) with BMI ≥18.5 ; Pregnant and lactating-with MUAC ≥ 23 cm,; Children: Under 5 years -WHZ-score above the -2 or WHM greater than 80% ; and Children :5-18 years -BMI for-Age Z- score above the -2 Lower space: Enter the data on which nutritional treatment outcome assigned date in EC using DD/MM/YY.

73 DR TB Treatment outcome

Upper space: Enter the DR TB treatment outcome of the patient as described (Cured; Completed; Failed; Died; Lost to follow up; Not Evaluated; and use blank space to write any other outcome other than listed ) Lower space: Enter the DD/MM/YY of the DR TB treatment outcome given by TIC

74 Remarks Write any remarks relate to patient care, treatment,outcome, etc ...

MDR TB Reg. Number

Name of patient Sex (M/F)

Name of contact Person

Elig

ibilit

y1.

Shor

ter re

gimen

2.

Long

er re

gimen

3.

Indiv

iduali

zed r

egim

en4.H

r-TB

regim

en

Registration Gruop

(1,2,3,4,5,6,7)

Weig

ht mo

nitor

ing

BMI

Intensive phase

Treatment started

(DD/MM/YY)

Smear Result (P/N/U)

Culture Result (P/N/U)

Write the

Month

Days: Intensive Phase treatment Monitroing chart

Refering Facility Name

Address of Patient (Woreda, kebele, H.No. Phone No.)

Age Address of contact

person (Woreda,

kebele, H.No. Phone No.)

Pul/EP

Drugs Dose 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 26 27 28 29 30Height (cm)

Resistance type (Hr-TB/

RR/MDR/ Pre-XDR/

XDR )(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44)

Drug Resistant TB Follow up Register

Drug AbbreviationsFirst line drugs: H= Isoniazid R= Rifampicin E=Ethambutol Z= Pyrazinamide S = Streptomycin Second-line drugs : Amx-Clv=Amoxicillin-clavulanate Cm=Capreomycin Ofx=Ofloxacin Lfx=Levofloxacin Mtx=Moxifloxacin Pto=Prothionamide Eto=Ethionamide Cs=Cyclosrine PAS=Pra amino Salicyclic acid Am=Amikacin Lzd= Linezoid Cfz= Clofazimine Bdq = Bedaquiline Dlm = Delamanid Cfz = Clofazimine Km =Kanamycin

Registration Group1. New 2. Relapse 3. Treatment After Lost to follow up 4.After failure of treatment regimen with FLD 5. After failure of treatment regimen with SLD 6.Transfer in from another DR TB Initiating center 7. Other, Specify and write the registration group in the remark if it is different from the list

Page 1

Continuation phase

Weig

ht mo

nitor

ing

BMI Smear

Result (P/N)

Culture Result (P/N)

Weekly attendance: Continuation Phase Treatment Monitroing Chart TB/HIV collaborative activities Adverse effect

Total HH and/or Close Contacts

(Number)

Total under 15 HH and/or Close Contacts Nutritional Assessment Outcome of DR TB

Treatment Cured Completed Failed Died LTFU

Not Evaluated Remarks

Drug DoseHa

mle

Neha

seMe

sker

emTik

imt

Hida

rTa

hisas

TirYe

katit

Mega

bitMi

aza

Ginb

otSe

ne Test

Result (P/N)

CPT (Y/N ) ART(Y/N ) Drug Action taken

Total contacts Screened for TB/ DR-TB (Number)

Total under 15 years contacts and/or Close contact Screened for

TB /DR TB

Status Management

Outcome: Recovered/cured Unchanged Other

(Specify)

Started date (DD/MM/YY)

Started date (DD/MM/YY)

Adverse effect

TB/DR TB Diagnosed among Contacts (Number)

Under 15 years TB/DR TB Diagnosed among

Contacts (Number)

Normal MAM SAM

1. Adivce2. Supplementary3. Therapeutic

Write nutritional treatment outcome & the date(DD/MM/YY)

Write DR-TB treatment outcome

& the date (DD/MM/YY)

(45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65) (66) (67) (68) (69) (70) (71) (72) (73) (74)

Drug Resistant TB Follow up Register

Page 2

Health Centre/Clinic/HospitalDrug Resistant TB Register


INSTRUCTIONS FOR DRUG RESISTANT TB REGISTER AT THE TREATMENT INITIATING CENTER/HEALTH FACILITIES (TIC)

Region Write region name where the DR TB-Treatment initiating center is locatedZone/Sub-City/Woreda Write Zone/sub-city/woreda/ where the DR TB-Treatment initiating center is located.Name of Health Facility Write the name of the health facility where the DR TB-Treatment initiating center is located.Register Begin Date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)Register End Date Write the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)

Register (HC/Clinic/Hospital-Drug Resistant TB Reg.) kept in drug resistant (DR) TB room and completed by the TB care provider.Location information to be completed at front of register:

S. No. Datum Description

1MRN/DR TB registerNumber

Upper Space: Enter the medical register number (MRN) of the patient given by the facility in the upper portion of the columnLower Space: Write a new unique patient identification number assigned by DR-TB treatment initiating center. The DR-TB unique number is assigned as:Region/Type of facility/facility code/five digit serial number with DR prefix. For instance, If a patient is started on SLD treatment at St peter hospital and is the 22nd patient to be put on SLD at the center.His/her unique DR number will be: 14/08/020/DR00022Please write only the five digit number with DR prefix on the space provided as the facility type and code are already written atthe top of each page

2 Treatment started date Write treatment-started date using Ethiopian Calendar (DD/MM/YY). Treatment start date is decided by the clinical team of the TICs; In most case the date of registration and date of start will be the same if the patient started the treatment upon arrival and if no other investigation/s are important before the start of the DR TB treatment.

3 Name in full Write patient name including, Father, and Grandfather4 Sex Write Sex as: M= Male and F= Female5 Age Write age in years

6 Address

Write full address of the DR-TB patient as follows: Upper space: enter name of region where DR TB patient resides.Second Space: enter name of zone where DR TB patient resides.Third Space: enter name of woreda where DR TB patient resides.Fourth space: enter phone number of DR TB patient

7 Resistance type Write “Hr-TB” for Isonized-resistant only, “RR” for Rifampicin-resistant only, “M” for MDR; “PX” for Pre-XDR; and “X” for XDR cases.8 Site of Disease Write the site of TB: “Pul” for pulmonary and “EP” for extra-pulmonary

NB: Patients with both pulmonary and extra pulmonary TB should be classified as a case of pulmonary TB.

9 Registration groupWrite the registration group Code listed below the register as:1. New 2. Relapse 3. Treatment After Lost to follow up 4. After failure of treatment regimen with FLD 5. After failure of treatment regimen with SLD 6. Transfer in from another DR TB Initiating center 7. Other, Specify and write the registration group in the remark if it is different from the list

10 Diagnosed by Write the DST diagnostic Technique used for the diagnoses of DR TB patient: Xpert, LPA, Phenotypic DST, and other WRD (Specify)11 Date sample taken for DST Write the date (DD/MM/YY) of the sample collected to make the diagnosis of DR TB not the date of the result collected12-25 Result of drug susceptibility testing

(DST) Write the DST result that is used to make the DR TB diagnosis. Write R=resistant S=susceptible I=Indeterminate (See treatment card for full history of DST data)

26 -27 Bacteriology

Col 26: Tick (ü) “bacteriologically Confirmed” if DR TB case confirmed by smear microscopy, culture or WHO approved Rapid Diagnostic Technology (such as Xpert MTB/RIF).Col 27: Tick (ü) “clinically diagnosed” for DR TB case who does not fulfill the criteria for bacteriological confirmation but has been diagnosed with active TB by Healthcare provider who has decided to give the patient a full course of DR TB treatment. This definition includes cases diagnosed on the basis of X-ray abnormalities or suggestive histology and extra pulmonary cases without laboratory confirmation. Clinically diagnosed cases subsequently found to be bacteriologically positive (before or after starting treatment) should be reclassified as bacteriologically confirmed.

28 Previously treated with first line drug (FLD) Write ‘Y’ for those patients who have taken first line drug for more than one month prior to registration and “N” for patient who has no history of drug use and those who has taken for less than one month.

29 Previously treated with second line drug (SLD) Write ‘Y’ for those patients who have taken second line drug for more than one month prior to registration and “N” for patient who has no history of drug use and those who has taken for less than one month.

30 -36 TB/HIV collaborative activities

Col 30: Write “Y” if HIV test is done or “N” if not doneCol 31: Write HIV test date as DD/MM/YY in E.C.Col 32: Write “P” for positive HIV test result or “N” for Negative test resultCol 33: Write the code for target population category listed, below the register. An individual needs to be assigned only in one category that best describe him/her.

A. Female Commercial Sex workers (Not applicable for partner test)B. Long distance driversC. Mobile workers/daily laborersD. PrisonersE. OVC

Col 34: Write cotrimoxazole prophylactic therapy (CPT) start date as DD/MM/YY in E.CCol 35: Write ART treatment started date as DD/MM/YY in E.CCol 36: Write Unique ART No in the appropriate place

37 Eligibility

Write the eligibility code as:“1” if the patient is eligible for shorter DR-TB regimen.“2” if the patient is eligible for longer DR-TB regimen “3” if the patient is eligible for individualized long term regimen “4” if the patient is eligible for isoniazid monoresistance TB regimen

38Nutritional Assessment:Classification

Interpret the anthropometry and enter the nutritional assessment result as follow: If normal, write “N”; if moderately undernourished, write “MAM”. If severely undernourished, write “SAM”

SAM criteria in Adults: MAM criteria in Adults: No Acute Malnutrition/Normal

· BMI <16 kg/m2 OR MUAC <18cm;· For pregnant women and lactating mothers MUAC <19 cm OR edema of both feet without clear cut other cause

· BMI 16 - <17.5 kg/m2 OR MUAC 18 - <21 cm· For pregnant women and lactating mothers: MUAC 19-

<23 cm OR· For HIV positive client: Confirmed (>5% weight loss since last visit) or reported weight loss (e.g. loose clothing) AND No edema of both feet

· BMI >17.5kg/m2 OR MUAC >21 cm· For pregnant women and lactating mothers >23 cm) AND No edema of both feet

39 Nutritional Management

Write Nutritional Management has given for a patient in the space provided: - If no intervention and only nutritional advices is provided enter “1”; if the patients has given supplementary food enter ”2”; and if patient is on Therapeutic Management enter ”3” NB: For DR-TB cases, those with severely undernourished (SAM) cases will receive the Ready -To-Use Therapeutic food (RUTF) andthose with moderately undernourished (MAM) cases receive Supplementary food (RUSF) based on availability of supplies.

40Nutritional treatment:Outcome

Upper space: Record the final outcome of the therapeutic or supplementary food treatment as: recovered/cured; No change; other outcome (specify)NB: The following arithmetic measure should be consider to label patients as recovered/cured from nutrition related problem, if Adult Kg/ (non-pregnant/lactating) with BMI ≥18.5 kg/m2; Pregnant and lactating-with MUAC ≥ 23 cm; Children: Under 5 years -WHZ-score above the -2 or WHM greater than 80%; and Children: 5-18 years -BMI for-Age Z- score above the -2Lower space: Write the data on which nutritional treatment outcome assigned date in EC using DD/MM/YY.

41 DR TB treatment outcomeUpper space: Write the outcome of the patient as described (Cured; Completed; Failed; Died; Lost to follow up; Not Evaluated; and use blank space to write any other outcome other than listed)Lower space: Write the DD/MM/YY of the DR TB treatment outcome given by TIC

42 Remark Write additional information of patient in the space provided

43 MDR TB regimen & date treatment started: Intensive phase

Upper space: Write the DR-TB intensive phase regimens using the drug abbreviations.Lower space: Write treatment started date using Ethiopian Calendar (DD/MM/YY)

44 MDR TB regimen & date treatment started: Continuation phase

Upper space: Write the DR TB continuation phase regimens using the drug abbreviations.Lower space: Write treatment started date using Ethiopian Calendar (DD/MM/YY)

45-78 Smear and culture monitoring resultsWrite all smear and culture results and the date (DD/MM/YY); use the same date for both if the test done within the same month. If more than one smear or culture done in a month, enter the most recent result.“P” for positive result using red pen; “N” for negative results and “U” for not done/results not available

INSTRUCTIONS FOR DRUG RESISTANT TB REGISTER AT THE TREATMENT INITIATING CENTER/HEALTH FACILITIES (TIC)

MRN

Treatment started

Date Name (in full)

Sex M/F

Age

Region

Resistance type ( Hr-TB, RR/ MDR/Pre

XDR/ XDR)

Site of Disease (P/EP)

Registration group*

Diagnosed by

Xpert, LPA, Phenotypic DST, Other WRD (specify)

Date sample taken

for DST( DD/

MM/YY

Result of drug susceptibility testing (DST)Enter the DST result that is used to make the DR TB diagnosis

R=resistant S=susceptible I=Indeterminate

DR TB Register

No S H R E Z Am Bdg

FLQ (Mfx/Lfx/ Ofx)

Pto /

EtoLnz PAS Cs Clz Dlm

Zone/ Subcity

Woreda/ Town

Phone Number

(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)

* Registration Group* 1. New 2. Relapse 3. Treatment A er Lost to follow up 4. A er failure of treatment regimen with FLD 5. A er failure of treatment regimen with SLD 6. Transfer in from another DR TB Initiating center7. Other, Specify and write the registration group in the remark if it is different from the list

Smear (S) and Culture (C) results during treatment(If more than one smear or culture done in a month, enter the most recent positive result)

MRN DR TB Treatment Month 0 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14

DR TB Register No

Regimen(intensive phase)

Date started

Regimen(Continuation phase)

Date started

S C S C S C S C S C S C S C S C S C S C S C S C S C S C S C

D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y

(1) (43) (44) (45) (46) (47) (48) (49) (50) (51) (51) (52) (53) (54) (55) (56) (57) (58)

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

DRUG RESISTANT (DR) TB TREATMENT REGISTER

DRUG RESISTANT (DR) TB TREATMENT REGISTER

No

Bacteriology profile

Previously treated with

TB/HIV collaborative Activities Eligible for 1. Shorter Regimen 2. Longer Regimen 3. Individualized long

Regimen4. Hr-TB regimen

Nutritional Assessment: Classification Management and outcome of treatment

OutcomeCured

CompletedFailedDied

Lost to Follow UPNot Evaluated

Moved to Pre/XDR TB RXRemark

Bact

erio

logi

cally

Con

firm

ed

( ü)

Clin

ical

ly D

iagn

osed

( ü

) Status Management Outcome

NormalMAMSAM

1. Nutritional advice

2. Supplementary

3. Therapeutic

Recovered/CuredUnchanged

Other(specify)HIV testing

CPT Started

(DD/MM/YY)

ART Started (DD/

MM/YY)Unique ART No.

Date outcomegiven

Date outcome given

First line drugs (Y/N)

Second line drugs (Y/N)

Testing done (Y/N/)

Date of test(DD/MM/YY)

Result(P/N)

Targetpopulation

Category Writecode**

(26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42)

/ / / / / /

/ /

/ / / /

/ /

/ / / /

/ / / /

/ /

Targeted population category** A. Female Commercial Sex workers, B. Long distance drivers, C. Mobile/Daily Laborers, D. Prisoners, E. OVC, F. Children of PLHIV, G. Partners of PLHIV, H. Other MARPS, I. General population

Smear (S) and Culture (C) results during treatment(If more than one smear or culture done in a month, enter the most recent positive result)

Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Month 25 Month 26 Month 27 Month 28 Month 29 Month 30 Month 31 Month 32 Month 33 Month 34

S C S C S C S C S C S C S C S C S C S C S C S C S C S C S C S C S C S C S C S C

D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y D/M/Y

(59) (60) (61) (62) (63) (64) (65) (66) (67) (68) (69) (70) (71) (72) (73) (74) (75) (76) (77) (78)

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /


Health Centre /Clinic/Hospital Leprosy Register for Care After

Completion of Treatment Register

Name of health facility:

Sr. No. Name

SexClassi-fication

MB/PBDate treatment

completed

Type of the Reaction and date started

Type of care given Is he/she organized in self care

group (yes or no)

Protective foot wearType of medications or care given

Referred to hospital

Type of foot wear given Reason for referral

AgeRR or ENL Size of foot wear Type of care/medication Name of HF refered to

Date Date given Date Date

TUBERCULOSIS AND LEPROSY CONTROL PROGRAMLeprosy register for care after completion of treatment


Health Centre /Clinic/Hospital Unit TB Register

INSTRUCTIONS FOR TB-UNIT REGISTERRegister (HC/Clinic/Hospital-TB DOTs Reg.) kept in TB-DOTS room, and completed by the TB care provider.Location information to be completed at front of register:

Region Write region name where the TB-DOTS center is located Zone/sub-city/ woreda Write the Zone/sub-city/ woreda where the TB-DOTS center is located. Health Facility Write the name of the health facility where the TB-DOTS center is located. Begin Date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY) End Date Write the date of the last entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)


1 Medical Record Number (MRN) Write unique individual identifier used on medical information folder for HC and hospital.

2 Unit TB No. Write TB unit identification number

3 Address of the TB patientUpper space: Write the patient’s name (individual, father, grandfather)

Lower space: Write the address of patient (woreda, kebele, House No, Phone No).

4 Sex (M/F)/AgeUpper space: Write the patient’s sex: M=Male; F=Female

Lower space: Write the patient’s age in years

5 TB Most at risk group* Write the appropriate code of TB Most at risk category (Key population) 1. Health care staffs including HEWs 2. Diabetes 3. Homeless

4. Refugee 5. Prisoners 6. Miners 7. Other congregated settings (University Students, Developmental mega project workers etc.) 8. Contacts 9. Others key population (other than 1-8) 10.0 General population

6Address of the contact person of the TB

patient

Upper space: Write the contact person’s name (individual, father, grandfather)

Lower space: Write the address of contact person: (woreda, kebele, House No, Phone No,)

7Linkage to the TB service (HEW, Public HF, PPM HF)

Write ‘HEW’ if the patient was initially identified and referred by Health extension worker including HCW working at Health post and Family health team from the community.

8 Rapid diagnostic tests as initial diagno-

sis

Write ‘Public HF’ if the registered TB patient was diagnosed and linked to receive treatment to TB unit within the same public Health facility or from another public health facility.

Write ‘PPM’ if the patient was referred to the health facility or TB clinic by Public/ Private mix (PPM) sites for TB diagnosis or to ini-tiate anti TB treatment. Note that PPM HFs includes public health facilities not directly under the scope of the national TB program including Prison, Uniformed Health facilities; NGO clinic, Faith Based Organization clinics and private health facilities. Note that if your clinic is a recognized PPM sites, enter ‘PPM HF’ for all registered TB patients on UNIT TB register and make sure that appropri-ate information on the type of PPM site is marked in the upper part of reporting formats before sending report to next higher level.

Write “Y” if TB patients diagnosed initially by X-pert; Write “N” if the TB patient initially diagnosed with other TB diagnostic meth-od.

Note that TB patient should have a result at the time of registration /enrolment on TB register.to be addedIdentification: Personal information

9 Rapid diagnostic test Result

Upper Space: Write Rapid diagnostic test Result type as:-

TB = MTB detected, rifampicin resistance not detected (use red pen) RR = MTB detected, rifampicin resistance detected (use red pen)

TI = MTB detected, rifampicin resistance indeterminate

N = MTB not detected

Lower space: Write Lab. Serial number of Rapid diagnostic test

10 Smear result

Upper space: Write the smear result as “P” for positive result using red pen; “N” for negative results and

“U” for not done/results not available

Lower space: Write Lab. Serial number of the smear test

11 Upper: Category (N, R, F, L, T, O)

Upper space: Write the patient’s category

N=New case: A patient who has never had treatment for TB or has been on anti-TB treatment for less than one month.

R=Relapse: A TB patient who have previously been treated for TB, were declared cured or treatment completed at the end of their most recent course of treatment, and are now diagnosed with a recurrent episode of TB (either a true relapse or a new episode of TB caused by reinfection).

F=Treatment after Failure: Treatment after failure patients are those who have previously been treated for TB and whose treat-ment failed at the end of their most recent course of treatment.(it is similar with previous definition, a patient who, while on treat-ment remained smear or culture positive at the end of the five ‘months’ or later, after commencing treatment)

L= Treatment after loss to follow-up: patients who have previously been treated for TB and were declared lost to follow-up at the end of their most recent course of treatment.

T=Transfer in: A patient who started treatment in one health facility (reporting unit) and transferred to another health facility (re-porting unit) to continue treatment.

O=Other previously treated patients: are those who have previously been treated for TB but whose outcome after their most recent course of treatment is unknown or undocumented

Lower space: Write the type of TB

P/Pos= Bacteriologically confirmed pulmonary TB cases using available confirmatory diagnostic methods

P/Neg= Clinically diagnosed pulmonary TB cases

EPTB= Extra-pulmonary TB cases (Bacteriologically & clinically diagnosed)

12Nutritional Assessment and status:

Weight (Kg), Height (cm), BMI (kg/m2)/MUAC (cm)

Upper space: Write the weight of the patient in Kg.

Middle space: Write the patient’s height in centimeters

Lower space: Write the BMI and value. BMI is computed as weight in kg divided by height in meter square. For patient age 5-18 years, use BMI- for-age and refer standard charts. Measure and enter MUAC in cm for pregnant, bedridden or under-five patient

13Nutritional Assessment and status:

(Normal, MAM, SAM)

Interpret the anthropometry and enter the result as either “Normal”; “MAM” or “SAM”: SAM criteria in Adults: • BMI <16 kg/m2 OR MUAC <18cm;for pregnant women and lactating mothers MUAC <19 cm OR oedema of both feet without clear cut other cause MAM criteria in Adults: • BMI 16 - <17.5 kg/m2 OR MUAC 18 - <21 cm • For pregnant women and lactating mothers: MUAC 19- <23 cm OR • For HIV positive client: Confirmed (>5% weight loss since last visit) or reported weight loss (e.g. loose clothing) AND No oedema of both feet No Acute Malnutrition/Normal • BMI >17.5 kg/m2 OR MUAC >21 cm •For pregnant women and lactating mothers >23 cm) AND No oedema of both feet

14 Intensive phase: Drug Write the treatment regimen (Fixed Dose Combination) used in the intensive phase

15 Intensive phase: Dose Write the treatment dosage of (Fixed Dose Combination) used in the intensive phase

16 Treatment Started (DD/MM/YY) Write the date TB treatment started in E.C (DD/MM/YY)

17 Write the month

Write the name of month for each month of intensive treatment as follows: If treatment begins in Tikmt, write “Tik” on the first line of column

16. When the month is completed, and if the patient continues treatment, write the name of the next Month Hidar as “Hid” on the second line of column 16, etc, for as long as intensive phase treatment continues.

18-47

Days of month Tick (√) each day the patient receives DOTS treatment and Mark (X) for days not receiving DOTS treatment.

TB / HIV Co infection48 HIV test offered Tick (√) if HIV test offered under provider initiated HIV counseling and testing guidelines

49 HIV test performed Tick (√) if client tested for HIV/AIDS.

50Targeted population category write code**

Write the following code from the list of target population category listed; an individual needs to be assigned only in one category that best describe him/her.

51 HIV Test results

A. Female Commercial Sex workers F. Children of PLHIV B. Long distance drivers G. Partners of PLHIV C. Mobile/Daily Laborers H. Other MARPS

D. Prisoners I. General population

E. OVC

Write “P” in red pen if test is Positive or the patient has documented evidence of enrolment in HIV care such as enrolment to pre-ART register or in the ART register

Write “N” in normal color of pen if test is Negative at the time of TB diagnosis.

If the test result is ‘inconclusive’ repeat the test and write the final test result.

Write “U” if HIV testing is not done or no other documented evidence of enrolment in HIV care52 Enrolled in HIV care (DD/MM/YY) Write the date patient enrolled in HIV care written as (EC) Day / Month / Year (DD/MM/YY)

53 CPT Started (DD/MM/YY) Write the date CPT started, written as (EC) Day / Month / Year (DD/MM/YY)

54 ART

Upper space: Write the date patient started ART, written as (EC) Day / Month / Year (DD/MM/YY)

Lower space: Write the unique ART number for a patient who started ART Treatment in the same facility. If the patient referred to other facility, write as “referred to other facility”. NB: It is the responsibility of the TB focal person of the facility to ensure the effectiveness of referral linkage and its outcome of the patients to the patient preferred and nearest ART Clinic.

55 DST after enrolled to TB treatment

Upper space

Write Y=Yes if the patient is presumptive DR-TB as per the national guideline

Write N=No if the patient is NOT presumptive DR-TB as per the national guideline

Lower space:Write No RR - if the DST result of the patient show no resistance at least to Rifampicin

Write ’RR-TB’ if patient DST result is resistance to Rifampicin only

Write Hr-TB—If resistance to INH only

Write MDR-TB’= if patient DST result of the patient is resistance to both Rifampicin and INH (MDR-TB)

Write Pre-XDR – if the DST result of the patient shows resistance to Isoniazid and rifampicin and either a fluoroquinolone or sec-ond-line injectable drugs but not both.

Write XDR= if the DST result of the patient show resistance to any fluoroquinolone and at least one additional group A drug (Be-daquiline or Linezolid)

56Name of HF and DR-TB Treatment start-

ed date and Unique DR -TB Number

Upper space: If the patient confirmed with DR TB, Write the name of the health facility that the patient referred for treatment

Middle space: Write treatment started date using Ethiopian Calendar (DD/MM/YY)

Record the date when the clinical team decided that the patient deserve DR-TB treatment; in most case the date of registration and date of start will be the same if the patient started the treatment upon arrival and if no other investigation/s are important before the start of the DR-TB treatment.

Lower Space: Write a new unique patient identification number assigned by DR TB treatment initiating center. The DR-TB unique number is assigned as follows:

Region/Type of facility/facility code/five digit serial number with DR prefix.For instance, If a patient is started on SLD treatment at St peter hospital and is the 22nd patient to be put on SLD at the center. His/her unique MDR number will be: 14/08/020/DR00022

Please write only the five digit number with DR prefix on the space provided as the facility type and code are already written at the top of each page

57Contacts screening and treatment: Age

0-4 years old Children Contacts

Upper space: Write total number of 0-4 years old Children Contacts with index TB case (Number)

Middle space: Write the number of 0-4 years old Children Contacts screened for TB at HF at least once (Number)

Middle Space: Write the number of 0-4 years old Children Contacts screened for TB and free from sign and symptom of TB

Lower space: Write number of 0-4 years old Children Contacts free from TB and put on IPT


5-14 years old children contacts

Upper space: Write total number of 5-14 years old children contacts with index TB case (Number)

Middle space: Write the number of 5-14 years old children screened for TB at HF at least once (Number)

Middle Space: Write the number of 5-14 years old children contacts screened for TB and free from sign and symptom of TB

Lower space: Write number of 5-14 years old children contacts free from TB and put on IPT


>15 years old contacts

Upper space: Write number of >15 years old contacts with index TB case (Number)

Middle space: Write the number of >15 years old contacts screened for TB at HF at least once (Number)

Middle Space: Write the number of >15 years old contacts screened for TB and free from sign and symptom of TB

Lower space: Write number of >15 years old contacts free from TB and put on IPT

60-62

Sputum results/ Lab serial numberUpper Space: Write Sputum results as “P” for positive result using red pen; “N” for negative results and “U” for not done/results not available in second, fifth and six month

Lower Space: Lab. Serial number of the sputum smear test in second, fifth and six month

63Nutritional Assessment: End of second

month of treatment:

Upper space: Write the weight of the patient in Kg.

Lower space: Write the BMI value in kg/m2. BMI is computed as weight in kg divided by height in meter square. For patients age 5-18 years, use

BMI-for-age and refer a standard chart. Measure and enter MUAC in cm for pregnant & lactating women, bedridden or under-five patient

64 Nutritional Assessment: classification See description on column #13 above and enter the classification in the space provided.

Continuation phase information

65 Continuation phase: Drugs Write the TB drugs therapy used in the continuation phase

66 Continuation phase: Dose Write the TB drugs therapy dosage used in the continuation phase

67 -80

Continuation phase: weekly adherence monitoring chart

Write the date in the appropriate week row of the month, when the TB client collects the weekly doses of TB treatment

81Final treatment outcome and Date

treatment outcome assigned

Upper space: Write final outcome of TB treatment:

Cured: A pulmonary TB patient with bacteriologically confirmed TB at the beginning of treatment who completed treatment as recommended by the national policy, with evidence of bacteriological response and no evidence of failure.

Treatment completed: A TB patient who completed treatment without evidence of failure BUT with no record to show that spu-tum smear or culture results in the last month of treatment and on at least one previous occasion were negative, either because tests were not done or because results are unavailable.

Treatment failure: A patient whose treatment regimen needed to be terminated or permanently changed to a new

Regimen or treatment strategy.

Died: A TB patient who died before starting treatment or during the course of treatment.

Lost to follow up: A TB patient who did not start treatment or whose treatment was interrupted for 2 consecutive months or more.

Not evaluated: A TB patient for whom no treatment outcome is assigned. This includes cases “transferred out” to another treat-ment unit as well as cases for whom the treatment outcome is unknown to the reporting unit.

NB: If patient is transferred out to another facility, write the receiving HF name and contact address on the remark place with pencil and confirm the final result and report to the next level during the appropriate reporting period.Lower space: Enter the date on which final outcome is assigned in EC (DD/MM/YY)

82 Nutritional interventions Upper space: Write the type of nutritional treatment as “RUTF” or “RUSF”

Plumpy nut is energy dense fortified therapeutic food (RUTF) designed for the treatment of SAM. Plumy sup is an energy dense fortified supplementary food (RUSF) designed for treatment of MAM. Lower space: Write the data on which nutritional treatment is started in EC using DD/MM/YY.

83 Nutritional treatment: OutcomeUpper space: Write the final outcome of the therapeutic or supplementary food treatment as: recovered/cured; No change; other outcome (specify) The following arithmetic measure should be consider to label patients as recovered/cured from nutrition related problem, if Adult (non-pregnant/

84-85

TB Treatment Adherence support

lactating) with BMI ≥18.5 kg/m2; Pregnant and lactating-with MUAC ≥ 23 cm,; Children: Under 5 years -WHZ-score above the -2 or WHM greater

than 80% ; and Children :5-18 years -BMI for-Age Z- score above the -2

Lower space: Write the data on which nutritional treatment outcome assigned date in EC using DD/MM/YY.

Tick (√) under Health Post if individual patient received support for TB treatment adherence (all efforts and services provided in-cluding treatment observation, adherence counseling, pill counting and other activities to monitor both the quantity and timing of the medication taken by a patient) at health post by HEWs at least during continuation phase of the treatment.

Tick (√) under Health facility If the treatment adherence support provided by the health care worker at health facility throughout the course of the treatment

86 Remarks Write any additional information about the patient that may assist the treatment provision service.

MRN Unit TB No.

Name of the patient Sex (M/F)

TB M

ost a

t ris

k gr

oup*

Name of con-tact person

Link

ed to

TB

serv

ice

by

( HEW

, Pub

lic H

F, PP

M H

F)

Test

with

rapi

d di

agno

stic

test

s (Xp

ert a

nd o

ther

s) a

t th

e tim

e of

dia

gnos

is(in

itial

dia

gnos

is)

(

Yes;

No) Rapid diagnistic

test Result ( TB, RR, TI and N)

Smear result

Category N.R.F.L.T.O

Nutritional Assessment and Status Intensive phase

Trea

tmen

t sta

rted

(DD/

MM

/YY)

Writ

e th

e m

onth

Intensive phase treatment monitoring chartWeight (kg)

Normal MAM SAM

Address of the patient (Woreda, Kebele, Hno.,-

Phone No.)Age

Address contact person

(Woreda, Kebele, H.No.,-

Phone No. )

Lab. no.

Lab. no.

P/Pos, P/Neg or EPTB

Height (cm)

Drugs Dose

Days:

BMI (kg/cm2)/

MUAC(cm)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 26 27 28 29 30

(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) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (45) (46) (47)

TB Most at risk category* (Key population) 1. Health care staffs including HEWs 2. Diabetes 3. Homeless 4. Refugee/IDP 5. Prisoners 6. Miners 7. Other congregated settings ( University Students, Developmental mega project workers etc ) 8. contacts 9. other Key populations (other than 1-7) 10. General Population

UNIT TB REGISTER

UNIT TB REGISTERTB/HIV collaborative service

ART started (DD/MM/

YY) DST after enrolled to

TB treat-ment(Y/N)

If DR-TB Confirmed, linked to (Name of

HF)

Number of Contacts, contacts screened, being Nega-tive and Put on TPT

Sputum results

Nutritional Assessment and Status (End of 2nd Month)

Continuation phase

Continuation phase treatment monitoring chart weekly attendance Cured

Completed Failure Died

Lost to Follow Up Not Evalu-

ated

Nutritional intervention and Outcome

TB Treatment Adherance

support pro-vided at

Remarks

HIV

test

offe

rred

(√)

HIV

test

per

form

ed (√

)

Targ

eted

pop

ulati

on c

ateg

ory*

* w

rite

code

HIV

test

resu

lt (R

or N

R or

Unk

now

n)

Enro

lled

in H

IV c

are

(DD/

MM

/YY)

CPT

star

ted

(DD/

MM

/YY

Age 0-4 years children Con-

tacts (Number)

Age 5-14 years children Contacts

Age > 15 years Contacts (Num-

ber)

Weight (kg) Normal MAM

SAM

Type of treatment: (RUTF) or Plumpy

nut/ (RUSF) or Plumpy sup

Outcome of treatment: recovered/cured ; No

change; other out-

come(specify)


tacts Screened for TB (Number)

Age 5-14 years children Contacts Screened for TB

(Number)

Age > 15 years Contacts Screened for TB

(Number)

Lab serial No.

Unique ART No.

DST Result (No RR ,

Hr-TB , RR, MDR, Pre-XDR, XDR)

Date DR TB started (DD/MM/

YY)


tacts screened Negative (Num-

ber)

Age 5-14 years children Contacts screened Nega-tive (Number)

Age > 15 years Contacts screened

Negative (Num-ber) 2 5 6 Drugs Dose

Wee

k of

the

Mon

th

Month:

Heal

th F

acili

ty

Heal

th P

ost

Unique DR TB ID

Age 0-4 years children put on

TPT (Number)

Age 5-14 years children put on TPT (Number)

Age > 15 years Contacts put on TPT (Number)

BMI (kg/cm2)/MUAC

(cm) Ham

Neh Pa

g

Mes Tik

Hid

Tah

Tir

Yek

Meg

Mia

Gin

Sen Date outcome

assigned in EC (DD/MM/YY):

Nutritional treat-ment started date

in EC (DD/MM/YY):

Date outcome assigned in EC (DD/MM/YY):

(48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65) (66) (67) (68) (69) (70) (71) (72) (73) (74) (75) (76) (77) (78) (79) (80) (81) (82) (83) (84) (85) (86)

__/___/___

W1

W2

__/___/___ W3

___/___/___ ___/___/___ ___/___/___

W4

__/___/___

W1

W2

__/___/___ W3

___/___/___ ___/___/___ ___/___/___

W4

__/___/___

W1

W2

__/___/___ W3

___/___/___ ___/___/___ ___/___/___

W4

__/___/___

W1

W2

__/___/___ W3

___/___/___ ___/___/___ ___/___/___

W4

Targeted population category** A. Female Commercial Sex workers, B. Long distance drivers, C. Mobile/Daily Laborers, D. Prisoners, E. OVC, F. Children of PLHIV, G. Partners of PLHIV, H. Other MARPS, I. General population

Health Post ToolsContent / Home

Content / Home

Pastoralist Registers, CHIS register, card and Tally sheets

Federal Ministry of Health

Health Service Reminder Card (Child Health)

IdentificationName of Health Post ___________________________________ Woreda _____________________Date of registration ____/____/________ Kebele ______________________Name of Child One:____________________________DOB: ___/___/___ Gote_________ _______________

EPIVisits BCG Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Remark

Date __/___/___ __/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___Visits OPV0 OPV1 OPV2 OPV3 IPV Fully immunized Remark

Date of visit __/___/___ __/___/___ ___/___/___ ___/___/___ ___/___/___

Visits PAB PCV1 PCV2 PCV3Measles 1st

dose Measles 2nd

dose RemarkDate of visit __/___/___ ___/___/___ _/___/___ ___/___/___ __/___/___ Next Visit date __/___/___ __/___/___ _/___/___ ___/___/___ ___/___/___ ___/___/___

Growth Monitoring 1st Visit 2nd Visit 3rd Visit 4th Visit Remark

Weight Height Z score Vitamin A Deworming MUAC in cm Edema Name of Child Two ________________________ DOB _________________________

EPIVisits BCG Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Remark

Date __/___/___ __/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___Visits OPV0 OPV1 OPV2 OPV3 IPV Fully immunized Remark

Date of visit __/___/___ __/___/___ ___/___/___ ___/___/___ ___/___/___

Visits PAB PCV1 PCV2 PCV3Measles 1st

dose Measles 2nd

dose RemarkDate of visit __/___/___ ___/___/___ _/___/___ ___/___/___ __/___/___

Next Visit date __/___/___ __/___/___ _/___/___ ___/___/___ ___/___/___ ___/___/___Growth Monitoring

1st Visit 2nd Visit 3rd Visit 4th Visit RemarkWeight Height Z score Vitamin A Deworming MUAC in cm Edema

Federal Ministry of HealthHealth Service Reminder Card (Maternal Health)

Name of Health Post ___________________________________________Name of woman ___________________________________ Gravidity _____________________Age _________________ Parity ______________________Woreda _____________________ LMP _______________Kebele ______________________ EDD _____________________________Gote________ _______________ Date of registration ____/____/________

Pregnancy Follow upVisits 1st Visit 2nd Visit 3rd Visit 4th Visit Remark

Date of visit ___/___/____ ___/___/_____ ___/___/____ ___/___/_____

GA Weight MUAC Iron TT (dose no) Mebendazole Danger sign (Y/N)

Health facility type

Woreda

Remark

Delivery/LaborPostnatal care

Delivery date ___/___/_____ Visits 0-24 hrs 25-48 hrs 49-72 hrs

73 hrs -7 days

8 - 42 days

Normal Y/N Date of visit __/__/__ __/__/__ __/__/__ __/__/__ __/__/__

Complicated and referred Y/N Place of PNC (Hospital/HC, HP, Home)

Place of delivery Hospital Health center

Health post Home

Counseled on maternal care

Weight (in gram) __________________ Counseled on newborn care

Family PlanningVisits 1st Visit 2nd Visit 3rd Visit 4th Visit 5th Visit 6th Visit Remark

Date of visit ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___

Method

Next visit ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___

Tetanus Toxoid (TT) VaccinationVisits TT1 TT2 TT3 TT4 TT5 Remark

Date of visit ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___

Next Visit Date ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___

Health PostCurative Care Register

Region Woreda Kebele Health Post Name

Begin Date End Date

Health PostCurative Care Register

Identification

Sig

n &

Sym

ptom

(C/C

)

Malaria related info

Dis

ease

Cla

ssifi

catio

n (If

Pat

ient

re

ferr

ed, w

rite

“ ref

erre

d”)

Type of visit

TB Screening

Provider Initiated HIV Counseling

& Testing (PIHCT)

Act

ion

take

n (T

reat

men

t giv

en)

If re

ferr

ed, R

easo

n fo

r Ref

erra

l

Remark/ Appointment (referral site)

Ser

ial

No.

Ser

vice

Dat

e (D

D/M

M/Y

Y)

Full

Nam

e

Age

Sex

(M

/F)

Wor

eda

Keb

ele

Got

e

TravelHistory(Yes/No)

RDTresult(N,PF,PV,Mixed)

New

(√)

Rep

eat (

√)

Scr

eene

d fo

r TB

(√)

TB s

cree

ning

resu

lt (P

/N)

HIV

Tes

t Offe

red

(√)

HIV

Tes

t per

form

ed (√

)

HIV

Tes

t res

ult

(P o

r N)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22)

Curative Care Register

Age in month (M) if under 1 year, and in days (D) if under 1 month Disease classification: write the diagnosis in NCOD

Health PostDevelopmental Nutrition Service

Register


Begin Date End Date

Health Post Developmental Nutrition Service

Register

S.No


GMP for under 2 years children Year: _________________

Micronutrient supplementation

RemarksDate

(DD/MM/YY)

Visit Date (DD/MM) Vitamin A

(DD/MM/YY)Deworming (DD/MM/YY)

Name Woreda Weight (kg)

Age (MM)

Kebele Height (cm)

Sex (M/F) Z-score of WFA

Mother/Guardian Gote Nutritional status

(N, MU, SU)*


Age (MM)

Kebele Height (cm)



(N, MU, SU)*


Age (MM)

Kebele Height (cm)



(N, MU, SU)*


Age (MM)

Kebele Height (cm)



(N, MU, SU)*


Age (MM)

Kebele Height (cm)



(N, MU, SU)*

NB:- N: Normal*; MU: Moderately Underweight; SU: Severely Underweight Growth Monitoring and Promotion register Version 01

Developmental Nutrition register for under Five Children

Health PostExpanded Program of Immunization

(EPI) Register


Begin Date End Date

Health PostExpanded Program of Immunization

(EPI) Register

Personal Information Antigens received Date (DD/MM/YY) PAB

Serial No.

Name of Infant

Age

Name ofMother

Woreda

Dos

e nu

mbe

r

BCG OPV DPT-HepB-Hib (Pentavalent) PCV Rota IPV Measles

Fully

im

mun

ized

by

first

birt

hday

(√)

Mot

her r

ecei

ved

TT 2

+ in

last

pr

egna

ncy (√)

Mot

her r

ecei

ved

TT 3

+ in

her

lif

e(√)

Pro

tect

ed a

t bi

rth (P

AB

)(√)

Reg. Date(DD/MM/

YY)

Sex (M/F)

Kebele

Gote

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)

0

1

2

3

0

1 2 3

0

1 2

3

0

1 2 3

0

1 2 3

0

1 2 3

Expanded program of Immunization Register Version 01

Expanded Program of Immunization (EPI) Register

Health PostFamily Planning (FP) Register


Begin Date End Date

Health PostFamily Planning (FP) Register

Health Post Family Planning Register

Personal Information Category Family Planning Service TT Remark/

AppointmentSerial No.

Full NameAge Kebele

New

A

ccep

tor

(√)

Rep

eat

acce

ptor

(√

)

Visi

t nu

mbe

r

Visit Date (DD/MM/YY)

Blood pressure (mmHg)

Type of contraceptive

provided

Amount given

Reason for method

switch

TT

prov

ided

(d

ose

no)

Date (DD/MM/YY) Sex Gote

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Use Abbrevation For col. 10 Inj=Injectabile OC=Oral contraceptive Fec=Female condome Imp=Implant Oth=Others Mc=Male condom

Reason for method switch for col. 12a) On recommended time d) Side effectb Want to get pregnant) e) Others) c)Misconception f)unavailability of the method

Health PostMaternal and Newborn Health

(MNH) Register


Begin Date End Date

Health PostMaternal and Newborn Health

(MNH) Register

Page | 1

INSTRUCTION FOR MATERNAL AND NEWBORN HEALTH SERVICE REGISTER AT HEALTH POST

The Maternal and Newborn Health register will be kept at health post and completed by the health worker at the health post (Nurses/HEWs/FLWs) Location information at the front part of the register

Data Element Description Region Write the region where the health post is located Woreda Write the woreda where the health post is located Kebele Write the kebele where the health post is located Health post Name Write the name of the health post where MNH services are provided

Register begin date Enter the date of the first entry in the register, written as Ethiopian Calendar (EC) Day/Month/Year (DD/MM/YY)

Register end date Enter the date of the last entry in the register, written as (EC) Day/Month/Year (DD/MM/YY)

Detail client information in the inside part of the register Category S.N Data Element

Description


1 Serial Number Sequential serial number in registration book, to be entered on client's

registration card for later identification in register

Registration Date The date on which a pregnant woman is registered in MNH register, written as (EC) Day/Month/Year (DD/MM/YY)

2 Name Full name of client 3 Age Age in years

4 Kebele Name of kebele where the client lives Gote Name of Gote where the client lives

Focused Antenatal

Care

5 Last Menstrual Period The date on which a client's last menstrual bleeding began, written as (EC)

Day/Month/Year (DD/MM/YY) Expected Date of Delivery (EDD)

The date on which client's expected to deliver, written as (EC) Day/Month/Year (DD/MM/YY)

6 Gestational Age (in weeks) Age of the current pregnancy in weeks 7 Visit number Number of ANC visits for this pregnancy

8 Date of visit (DD/MM/YY) Date when ANC visit is made, written as (EC) Day/Month/Year (DD/MM/YY)

9 Weight (Kg) Write the weight of the pregnant mother in Kg 10 BP Write BP reading of the pregnant mother 11 MUAC (cm) Write MUAC of the pregnant mother in cm 12 HIV Test accepted(√) Tick (√) for women accepted HIV test

13 HIV Test result (P/N) Write” P” for women tested positive for HIV and write “‘N’ for women received HIV negative

14 Client counseled and Referred for ART Tick (√) for women who HIV positive and referred to HF for ART

15 Iron supplementation (no of tabs)

If Iron or Iron folic acid is provided for pregnant women, write the number of tablets provided per visit otherwise leave it blank

16 TT provided (dose number) If TT immunization is provided, enter dose number; otherwise leave it blank

17 Mebendazole provided (√) Tick (√) If mebendazole is provided for the pregnant woman, otherwise leave it blank

18 Advised on danger sign (√) Tick (√) If advice on danger sign is given for pregnant women, if not leave it blank.

Page | 2

Category S.N Data Element

Description

19 Advised on birth preparation (√)

Tick (√) If advice on birth preparation is given for pregnant women,; if not leave it blank.

20 Advised on maternal nutrition (√)

Tick (√) If advice on maternal nutrition is given for pregnant women,; if not leave it blank.

21 Counseled on breastfeeding (√)

Tick (√) If advice on breastfeeding is given for pregnant women if not leave it blank.

22 ITN provided (√) Tick (√) If ITN is provided for pregnant women, if not leave it blank.

Delivery Services

23 Delivery date (DD/MM/YY) and time (00:00)

The date and time on which a client delivered, written as (EC) Day/Month/Year (DD/MM/YY) – 00:00

24 Place of delivery (write code)

Write place of delivery based on the code (HO: home, HP: health post, HC: health center, Hos: hospital, other)

25 Attendant Write the profession of birth attendant as Nurse. HEW, FLWs, TBA, or others

26 Received miso (√); Tick (√) If misoprostol is provided for the women after delivery, otherwise leave it blank.

Maternal status

27 Alive /Stable (√) Tick (√) If the mother is alive and her condition stable,; otherwise leave it blank.

28 Died (√) Tick (√) If woman is dead causes related to pregnancy and delivery, otherwise leave it blank.

Neonate status

29 Alive (√) Tick (√) If the neonate is alive, otherwise leave it blank. 30 Sex (M/F) Write M=for Male and F=for Female on the sex of the neonate 31 Weight in grams Write the weight of the neonate in grams 32 Still birth (√) Tick (√) If baby is born dead, otherwise leave it blank.

33 Neonatal death (age in days) If the neonate is dead, write the age of the neonate in days

34 If died, cause of death If the neonate is dead, write the cause of death of the neonate

Complication and

referral

35 Maternal complication

If there is any complication related to pregnancy and delivery, write the name of complication based on the code provided Maternal: (APH, PPH, OL/BD(obstructed labor or birth delay), fit, discharge, fever, swelling and severe headache or other complications other than listed here

Newborn Complication Newborn: breathing pro, sucking pro., LBW, fit, eye inf: cord inf, fever, unconscious, or other complications other than listed here

36 Referred (√) put tick mark (√) If client is referred to health facility, otherwise leave it blank

New Born preventive services

37 TTC oint (√) Tick (√) if TTC ointment given

38 Chlorhexidine (√) Tick (√)) if chlorhexidine used

PNC

39 Visit number Number of PNC visits for basic care for this pregnancy

40 Date of Visit (DD/MM/YY) Date when PNC visit is made, written as (EC) Day/Month/Year (DD/MM/YY)

41 PNC visit time Categorize the time of PNC visit and write 48hr= for 48 hours,7d=for 7 days, 42d=for 42 days

42 Advised on maternal care (√)

Tick (√) If advice on maternal care such as cleanliness, danger signs, family planning, etc … is given for delivered women,; if not leave it blank.

43 Advised on newborn care (√)

Tick (√) If advice on newborn care is given for delivered women, if not leave it blank.

44 Place where PNC provided Write place where PNC is provided based on the code (HO: home, HP: health post, HC: health center, Hos: hospital, other)

Remark 45 Remark/Appointment Write appointment date and any note

Personal Information Focused Antenatal Care

Serial No.

Name Age

KebeleLast

Menstrual Period

Gest

ation

al A

ge

(wee

ks)

Visit

num

ber

Date

of A

NC

visit

(D

D/M

M/Y

Y)

Wei

ght (

Kg)

BP

MUA

C (c

m)

HIV

Test

acc

epte

d (√

)

HIV

Test

resu

lt (P

/N)

Clie

nt c

ouns

eled

and

Re

ferr

ed fo

r ART

Iron

supp

lem

enta

tion

(# o

f tab

lets

)

TT p

rovi

ded

(dos

e no

)

Meb

enda

zole

pr

ovid

ed (√

)

Advi

sed

on d

ange

r sig

n (√

)

Advi

sed

on b

irth

prep

arati

on (√

)

Advi

sed

on m

ater

nal

nutr

ition

(√)

Coun

sele

d on

Bre

ast

feed

ing

(√)

ITN

pro

vide

d (√

)

Date(DD/MM/YY)

Gote EDD

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22)

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

MNH service register Version 01, page 01

Maternal and Newborn Health Service Register

Maternal and Newborn Health Service Register

Delivery Services Maternal status

Neonate status Complication and referralNew Bornpreventive

servicePostnatal Care

Remark/ Appointment

Delivery date (DD/MM/

YY) and time (00:00)

Plac

e of

del

iver

y

Atten

dant

Rece

ived

miso

(√)

Aliv

e/ S

tabl

e (√

)

Died

(√)

Aliv

e (√

)

Sex

(M/F

)

Wei

ght i

n gr

ams

Still

birt

h (√

)

Neo

nata

l dea

th

(age

in d

ays)

If di

ed, c

ause

of

deat

h

Maternal complication

Refe

rred

(√)

TTC

eye

oint

men

t (√)

Chlo

rhex

idin

e (√

)

Visit

Num

ber

Date of Visit

(DD/MM/YY)

PNC visit Time

Advi

sed

on

mat

erna

l car

e (√

)

Advi

sed

on

new

born

car

e (√

)

Plac

e w

here

PN

C pr

ovid

ed

Newborncomplication

(23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (45)

1234

512

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

(35) Maternal: APH, PPH, OL/BD, fit, discharge, swelling, fever, or other (41) 24hrs(1day), 48hrs(2days), 72hrs(3days), 7days or 42days

Newborn: sucking pro, breathing pro, LBW, fit, eye inf, cord inf, fever, unconscious, or other

(24) and (44) HO, HP, HC or Hos(25) Nurse, HEW, FLW, TBA or others

(34) Prematurity, Infection, Asphyxia, Cong. Mal, or others(25) Nurse, HEW, FLW, TBA or others

MNH service register Version 01, page 02

Health PostNTD Screening Register


Begin Date End Date

Health PostNTD Screening Register

S.No Name Age Sex

AddressScreening date

(DD/MM/YY)

NTD Cases screened (1,

2,3,4,5,6,7,8 or 9)

Linked/Referred for treatment

(yes/No)

Treatment outcome

(Improved, the same, dead)

Remarks Woreda Kebele Gote

Neglected Tropical Diseases (NTDs) Screening Register

NTD Diseases1. Cutaneous Leishmaniasis (CL)2. Visceral Leishmaniasis (VL)3. Dracunculiasis

4. Trachomatous trichiasis (TT) 5. Lymphedema6. Hydrocele

7. Schistosomiasis (SCH)8. Soil Transmitted Helminthiasis (STH)9. Onchocerciasis (Oncho)

Health PostNutrition Screening and TFP Register


Begin Date End Date

Health PostNutrition Screening and TFP Register

Malnutrition Screening and TFP register Version 01, page 01

Nutrition Screening and Therapeutic Feeding Program (TFP) Register for under five children

Personal Information Nutrition Screening Admission

Serial No.

Name of Child

Age

Name of Mother/Guardian Woreda

Kebele

MUAC (cm)

Oed

ema

(+,+

+,++

+)

Cla

ssifi

catio

n (N

,MA

M, S

AM

)**

If SAM, action taken (Admitted or

Referred)

Unique SAM No

New admission (Y/N)

Date

(DD/MM/YY)

Sex (M/F) Gote Transfer/

Readmission(Y/N)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

** NB: N:- Normal; MAM:- Moderate Acute malnutrition; SAM:- Sever Acute malnutrition

Health PostPregnant and Lactating Mother

Nutrition Screening Register


Begin Date End Date

Health PostPregnant and Lactating Mother

Nutrition Screening Register

Personal Information Nutritional Screening Counseling & Action taken

RemarksS.No Name of the Mother Age

WoredaPSNP*

beneficiary (Y/N)

Visit No.

Date of visit (Write day

DD/MM/YY)

Status (P/L)

Weight (kg)

MUAC (cm)

Classification (N or Malnourished)

If all Nutrition

Counseling Provided(√) (1,2,3,4,5,6)

Action taken

(A,B,C,D)Kebele

Gote

1 2

3 4

5 1 2 3 4 5 1 2 34512345

Pregnant and Lactating Women Nutrition Screening Register

Nutrition Counseling1 For Pregnant Women eat one extra meal every day2 For Lactating Women eat two extra meal every day3 Eat variety & diversified food4 Deworming at 2nd or third trimester (PW)5 IFA every day minimum at least 90 days plus6 Sleep under insecticide treated net

Action Taken• Counseling provided• Referred to TSFP• Referred to PSNP• Referred to other (specify)

P: Pregnant WomanL: Lactating WomanPSNP: Productive Safety-Net Program

N: Normal; MUAC>23 cm;Malnourished: MUAC <23 cm


Health Post Malaria Screening and Investigation

Register

SN Datum Comments

1 S.N Write serial number starting from 001 for the patient to document in the regsiter

2Examination Date (DD/MM/YY)

Write the date patient visitied the health facilitity, written as (EC) Day /Month / Year (DD/ MM/YY)

3 Full Name of Patients Write the patient’s first name and father name

4 MRN Write unique individual identifier used on medical information folder.

5 AgeIf the patient is less than 5 years of age, enter the patient’s age in months -MM For exam-ple, a 4-month-old child is entered as 04M. If the patient is 5 years of age or older, enter the patient’s age in years -YY. For example, a 6-year-old child is entered as 06


7 Pregnancy status (P/NP/NA) Write P= for Pregenant Women, NP= Non-Pregenant Women and NA= Not Applicable

8Address (Keble, Got, HH No.)/Phone No

Write Patient Keble, Got and/or House Hold Number on the upper row and the patient, Phone Number in the lower row

9History of fever in the last 48 hrs (Y/N)

Write fever history in the last 48 hours, Write Y= Yes for patient with fever history and N= No Fever history

10 Temperature (0C) Write the body temperatures taken under the arm using digital thermometer in ˚C

11Travel history (Qolama)(Y, N)/ Travel Place Location

Write history of travel to malarias area (Kolama area) in the last 30 days and stayed at least one night, Write Y= Yes has travel history, N= No travel history on the upper row and Write the name of traveled place in the lower row

12Diagnostic method (Mic/RDT/ Clinical)/Result ( N/Pf/Pv/Mix)

Write the diagnosis method used for the patients with malaria, Write Mic=Microspic, RDT=Rapid Diagnosis Method or Clinical = Clinical diagnosed by physicians in the upper row, Write the result of diagnosis N=Negative, Pf=Plasmodium falciparum, Pv= Plasmodium vivax, Mix=Mixed in the lower row

13Treatment* (1,2,3,4,5,6 and 7)

Write the treatment medication given, 1=ACT, 2=ACT+SLDPQ, 3= CQ, 4=CQ+RCPQ, 5=Artesu-nate Injection, 6= Other and 7=Referred

14A visitor case (Y/N)/ A visitor, Stayed for 21 days or more? (Y/N)

A passively detected case staying temporarily within HF catchment with his/her relatives during his/her illness or infection period but not permanent residence of the kebele Write Y=Yes, N=No / If the case is visitor and stayed for 21 days or more in the area, Write Y=Yes, N=No

15 Eligible for Investigation (Y/N) A passively detected case staying temporarily within HF catchment with or without defined address during his/her infection or illness period for less than 21 days, about 21 days or more than 21 days, Write Y=yes, N=No

16Date FTAT started (DD/MM/YY) /Date FTAT completed (DD/MM/YY)

Write the started date for reactive focal test and treat (FTAT) in the upper row and completed date in the lower row, written as (EC) Day /Month / Year (DD/ MM/YY)

17The index case investigated and classified (Y/N)

Write Y= Yes if the index case investigated and classified, N=No, if not investigated and not classified

18Number of HH members test-ed within 70 m radus from the index case

Write the number of people tested within 70 m radius from the index cases

19

Number secondary cases identified from the index case investigation/Number of imported secondary cases

Write the number of secondary cases identified from the index case investigation in the up-per row and number of imported cases from the secondary cases in the lower row

20Foci investigation done round the index case (Y/N)

Write Y= Yes if the foci investigation done around index case, N=No if foci investigation not done

21 Remark Write any supporting information

Instruction How To Complete Malaria Screening and Investigation Registration on Health Post

S.NExamination

Date (DD/MM/YY)

Full Name of Patients MRN Age Sex (M/F)

Pregency status (P/NP/NA)

Address (Kebele, Got,HH

No.)History of

fever in the last 48 hrs (Y/N)

Temperature (0C)

Travel history

(Qolama) (Y, N)/

Diagnostic method

(Mic/RDT/ Clinical) Treatment*

(1,2,3,4,5,6 and 7)

A visitor case (Y/N)

Eligible for Investigation

(Y/N)

Date FTAT started (DD/

MM/YY) The index

case investigated

and classified (Y/N)

Number of HH members tested within

70 m radus from the

index case

Number secondary cases identified

from the index case investigation?

Foci investigation done round

the index case (Y/N)

Remark

Phone #) Travel Place Location

Result ( N/Pf/Pv/Mix)

A visitor, Stayed for 21 days or

more? (Y/N)

Date FTAT completed (DD/MM/

YY)

Number of imported

secondary cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Health Post Malaria Screening and Investigation RegistrationRegion ………………………. Zone ...……………………… Woreda ...…………………… Kebele ……………………… Health Facility ……………… ………………………………

*Treatment Options: (Col. 13) 1=ACT, 2=ACT+SLDPQ, 3= CQ, 4=CQ+RCPQ, 5=Artesunate Injection, 6= Other and 7=Referred

ጤና ኬላ የተቀናጀ ማህበረሰብ ተኮር የጨቅላ ሕፃናት

ህክምናና እንክብካቤ መዝገብ (ከሁለት ወር እስከ 59 ወር)

ክልል ዞን / ክፍለ ከተማ / ወረዳ የጤና ተቋሙ ስም የተጀመረበት ቀን ያልቀበት ቀን

የተቀናጀ ማህበረሰብ ተኮር የጨቅላ ሕፃናት ህክምናና እንክብካቤ መዝገብ(ከሁለት ወር እስከ 59 ወር)

mmRÃ

k5 ›mT b¬C HÉÂT mZgBN bTKKL lmÑ§T kz!H b¬C ytzrz„TN n_ïC b_N”q& mmLkT xSf§g! nWÝÝ YH mZgB Sl HÉÂT HKMÂÂ XNKBµb@ y_‰T dr© lmgNzB y¸ÃSCL -”¸ mr© MN+ çñ XNÄ!ÃglGL çñ ytzUj nWÝÝ SlçnM b_‰TÂ btà§ mNgD mä§T YñRb¬LÝÝ

1 bz!H mZgB WS_ bÑl# mSmR ¬_é ¨GDM ytzrUW ú_N /row/ lxND b>t¾ mr© mmZgb!Ã XNÄ!çN tdR¯ ytzUj nWÝÝ kF BlÖ bR:S mLK ytqm-W ¨GDM mSmR XNd SM½ :D»½ ò¬½ KBdT½ wzt lmmZgB ytmdb ï¬ nWÝÝ

2 xNÄND ú_ñC bn-BÈB mSméC ytkfl# ÂcWÝÝ lMúl@ ymjmRÃW Ì*¸ ú_N /column/ bz!H ›YnT mSmR tkFl*LÝÝ k§Y qN s!ÉF k¬C t‰ q$$$_R YÉÍLÝÝ btmúúlY mLk# b2¾W Ì*¸ ú_N SM k§Y xD‰š k¬C YÉÍLÝÝ b3¾W Ì¸ ú_N :D» k§Y ò¬ k¬C½ b 4¾W Ì¸ ú_N KBdT k§Y ysWnT ÑqT k¬C mÉF xlbTÝÝ

3 HÉn# ymÈbT êÂ y-@Â CGR b¸lW Ì¸ ú_N ýS_ w§J Lj*N XND¬mÈ ÃSgdÄT êÂ y-@Â CGR bGL} mÉF xlbTÝÝ

4 mZgb# §Y ktÉûT yb>¬ MLKèC WS_ HÉn# §Y ytgßWN b¥KbB¿ KFT ï¬ãC §Y bmÉF wYM y‰YT MLKT √ b¥Sqm_ mZgb#N btà§ mNgD mÑ§T ÃSfLULÝÝ

5 ywsN>WN SÃ» wYM SÃ»ãC½ ys->WN HKMÂ mD¦n!T½¶fR µL> yt§kbT ï¬½ ÃdrG>WN KTTL¿ bKTTL wQT ytgßW yHKMÂ W-@T lÃNÄNÇ bts-#T tgb! ú_ñC bGL}Â btà§ mmZgB ÃSfLULÝÝ

6 HÉn#N bM¬k!¸bT wQT ¥N¾WM Wún@ k¥DrG> bðT ¥lTM yb>¬ SÃ» kmS-T> bðT½ mD¦n!T kmS-T> wYM ¶fR k¥DrG> bðT½ y¸ÃSfLgWN KTTL km-wsN> bðT ytgß#TN ykbB>ÃcWN yÉF>ÃcWN wYM y‰YT mLKT ÃdRG>ÆcWN mr©WC bÑl# bm-qM TKKl¾ Wún@ §Y XNDTdR¹! ÃGZšLÝÝ

7 HKMÂ¼XNKBµb@ ls-šcW HÉÂT bÑl# KTTL ¥DrG l!¬lF ymYgÆ tGÆR nWÝÝ YHN ¥DrG> ytà§Â ÃLtö‰r- HKMÂ mS-T ÃSCLšLÝÝ bt=¥rM y_rT>N W-@T bGL} l¥YT ÃSCLšLÝÝ

8 የተገኘው የጤና ችግር ስያሜ በESV-ICD11 መሰረት ስምና ኮድ ተለይቶ ይጻፍ፡፡

የተቀናጀ ማህበረሰብ ተኮር የጨቅላ ሕፃናት ህክምናና እንክብካቤ መዝገብ (ከሁለት ወር እስከ 59 ወር)ቀን ስም ዕድሜ

በወር ክብደት በኪ.ግ

ህፃኑ የመጣበትን ዋና የጤና ችግር

የህፃኑ ህመም ምልክቶች በተገኙበት ሁሉ ላይ አክብቢ ወይም ፃፊ የህፃኑ ህመም ምልክቶች በተገኙበት ሁሉ ላይ አክብቢ ወይም ፃፊቫይታሚን ኤ/እድሜ >

6 ወራት/ሌላ የጤና ችግር የተገኘው የጤና ችግር

ስያሜ

የተሠጠው ህክምና የክትትል ቀን የተገኘው የጤና ችግር ስያሜ በESV-ICD11 መሰረት

አስተያየትተ.ቁ አድራሻ (ቀበሌ /ንዑስ

ቀበሌ) ፆታ የክትባት ሁኔታ ሜቤንዳዞል/

አልቤንዳዞል/ እድሜ ≥ 2 አመት

የተሠጠው መድሃኒት አወሳሰድ እናትን ማማከር

እሪፈር ከተባለ የተላከበት ተቋም ስም የተሠጠው አጭር የቀጠሮ

ቀን ውጤት የበሽታው ስም ኮድ

የሰውነት ሙቀት አጠቃላይ አደገኛ ምልክቶች ሳል/ የአተነፋፈስ ችግር ተቅማጥ ትኩሳት የጆሮ ችግር የምግብ እጥረት/ደማነስ ኤች.አይ.ቪ ኤድ ቴበርክሎሲስ/ቲቢ/ የእድገት ዳሰሳ / < 2 ዓመት/ የተላከበት ተቋም ስም

አለው የለውም አለው የለውም አለው የለውም አለው የለውም አለው የለውም አለው የለውም የአሁኑን እድሜ ሁሉንም የዕድገት እርከኖች ደርሷል/ለች

አለው የለውም

________ _____ . __ *ለ ________ቀናት ; * ለ ________ቀናት < 6 ወር እድሜ * እናት: *14 ቀን እና ከዛ በላይ የቆየ ሳል * ያጠናቀቀ በለፈው 6 ወር ውስጥ * ስለ ምግብ የተሻለው

በወር በኪ.ግ *መጠጣት/መጥባት ያቃተው * ለ________ ቀናት * ደም የቀላቀለ * የወባ ተጋላጭነት፤ ያለው /የሌለው ፤ ባለፈው 1 ወር ወደ ወባማ ቦታ ሄዶ የነበር * የጆሮ ህመመ * የሚሰረጎድ የእግሮች እብጠት ፖዘቲቭ/ኔጌቲቭ/አይታወቅም *ኩሳትና የሌሊት ማላብ የአሁኑን እድሜ አንድ ወይም ከዝያ በላይ የዕድገት እርከኖች አለደረሰም/ችም ነገር ግን *የወሰደ*የወሰደውን በሙሉ እና * ትንፋሽ በደቂቃ * የፈዘዘ/አእምሮውን የሳተ * ለ ________ቀናት፣ከ 7ቀን በላይ በየቀኑ የነበረ ትኩሳት * የጆሮ ፈሳሽ * የሚታይ ከባድ የሰውነት ክሳት * ህፃን *መድሃኒት ከተላመደ ቲቢ የቀድሞውን እድሜ ሁሉንም የዕድገት እርከኖች ደርሷል/ለች * ጊዜውን የጠበቀ * ስለ ፈሳሽ እንደመጀመሪያው

በወሰደ ቁጥር የሚያስመልሰው ‘_______/ደቂቃ * የሚነጫነጭ/የሚወራጭ *ባለፉት 3 ወራት በኩፍኝ ተይዞ የነበረ፤የማጅራት መገተር/ የርግብግቢት ማበጥ ለ ________ቀናት > 6 ወር እድሜ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም ህመምተኛ ጋር የቅርብ አስጊ ሁኔታ ወይም የወላጅ/አሳዳግ ስጋት አለ

*ያልወሰደ ስለ ልጆች እድገት እንክብካቤ

ወ * ኮንቫልሽን የነበረው *ፈጣን አተነፋፈስ * የተሰረጎዱ ዓይኖች * መላ ሰውነትን ያደረስ የኩፍኝ ሽፍታ * የጆሮ ፈሳሽ /መግል *የሚሰረጎድ የእግሮች እብጠት ግንኙነት ያለው * ጊዜውን ያልጠበቀ በለፈው 6 ወር ውስጥ *መች መመለስ የባሰበት* ኮንቫልሽን አሁን አለው * ደካማ አጠጣጥ - ሳል/የተዝረከረከ አፍንጫ/የቀላ ዓይን * ከጆሮው ጀርባ ህመም *ሙዋክ < 11.5/ 11.5-<12.5/ >12.5 ሳ.ሜ *ከቲቢ ህመምተኛ (መድሃኒት የቀድሞውን እድሜ አንድ ወይም ከዝያ በላይ የዕድገት እርከኖች አለደረሰም/ሰችም * የወሰደ እንዳለባት

ሴ * የፈዘዘ/አዕምሮውን የሳተ * የደረት መሰርጎድ * ተስገብግቦ የሚጠጣ * አፉ የቆሰለ *ከጆሮው ጀርባ ህመም *ሳንባ ምች/ትኩሳ/ትውሃማ ተቅማጥ/የደም ተቅማጥ/ኩፍኝ ያልተላመደ) ጋር የቅርብየቀድሞውን አንድ ወይም ከዝያ በላይ ክህሎቶች አቷል/ታለች

* ያቋረጠ የሞተ

_____ . __ * ስትራይደር * የሆዱ ቆዳ ሲቆነጠጥ፤ * ዓይን አር/ ጥቁሩ ዓይኑ የነጣ ያለው እብጠት ካለው *የምግብ ፍላጎት ሙከራ ያለፈ/ያላለፈ ግንኙነት *ያልወሰደዲሴ ዘግይቶ/ ብጣም ዘግይቶ የሚመለስ * አርዲቲ፣ፖዘቲቭ/ኔጋቲቭ/አልተስራም * የእጅ መዳፍ መገርጣት/በመጠኑ/ያልገርጣ እብጠት ወይም የሚያዥ ቁስል በብብት/አንገት * ያልጀመረ ያልታወቀ







ወ * ኮንቫልሽን የነበረው *ፈጣን አተነፋፈስ * የተሰረጎዱ ዓይኖች * መላ ሰውነትን ያደረስ የኩፍኝ ሽፍታ * የጆሮ ፈሳሽ /መግል *የሚሰረጎድ የእግሮች እብጠት ግንኙነት ያለው * ጊዜውን ያልጠበቀ በለፈው 6 ወር ውስጥ *መች መመለስ የባሰበት

* ኮንቫልሽን አሁን አለው * ደካማ አጠጣጥ - ሳል/የተዝረከረከ አፍንጫ/የቀላ ዓይን * ከጆሮው ጀርባ ህመም *ሙዋክ < 11.5/ 11.5-<12.5/ >12.5 ሳ.ሜ *ከቲቢ ህመምተኛ (መድሃኒት የቀድሞውን እድሜ አንድ ወይም ከዝያ በላይ የዕድገት እርከኖች አለደረሰም/ሰችም * የወሰደ እንዳለባት






________ _____ . __ *ለ ________ቀናት ; * ለ ________ቀናት < 6 ወር እድሜ * እናት: *14 ቀን እና ከዛ በላይ የቆየ ሳል * ያጠናቀቀ በለፈው 6 ወር ውስጥ * ስለ ምግብ የተሻለውበወር በኪ.ግ *መጠጣት/መጥባት ያቃተው * ለ________ ቀናት * ደም የቀላቀለ * የወባ ተጋላጭነት፤ ያለው /የሌለው ፤ ባለፈው 1 ወር ወደ ወባማ ቦታ ሄዶ የነበር * የጆሮ ህመመ * የሚሰረጎድ የእግሮች እብጠት ፖዘቲቭ/ኔጌቲቭ/አይታወቅም *ኩሳትና የሌሊት ማላብ የአሁኑን እድሜ አንድ ወይም ከዝያ በላይ የዕድገት እርከኖች አለደረሰም/ችም ነገር ግን *የወሰደ

*የወሰደውን በሙሉ እና * ትንፋሽ በደቂቃ * የፈዘዘ/አእምሮውን የሳተ * ለ ________ቀናት፣ከ 7ቀን በላይ በየቀኑ የነበረ ትኩሳት * የጆሮ ፈሳሽ * የሚታይ ከባድ የሰውነት ክሳት * ህፃን *መድሃኒት ከተላመደ ቲቢ የቀድሞውን እድሜ ሁሉንም የዕድገት እርከኖች ደርሷል/ለች * ጊዜውን የጠበቀ * ስለ ፈሳሽ እንደመጀመሪያውበወሰደ ቁጥር የሚያስመልሰው ‘_______/ደቂቃ * የሚነጫነጭ/የሚወራጭ *ባለፉት 3 ወራት በኩፍኝ ተይዞ የነበረ፤የማጅራት መገተር/ የርግብግቢት ማበጥ ለ ________ቀናት > 6 ወር እድሜ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም ህመምተኛ ጋር የቅርብ

አስጊ ሁኔታ ወይም የወላጅ/አሳዳግ ስጋት አለ*ያልወሰደ ስለ ልጆች እድገት እንክብካቤ









በወር በኪ.ግ *መጠጣት/መጥባት ያቃተው * ለ________ ቀናት * ደም የቀላቀለ * የወባ ተጋላጭነት፤ ያለው /የሌለው ፤ ባለፈው 1 ወር ወደ ወባማ ቦታ ሄዶ የነበር * የጆሮ ህመመ * የሚሰረጎድ የእግሮች እብጠት ፖዘቲቭ/ኔጌቲቭ/አይታወቅም *ኩሳትና የሌሊት ማላብ የአሁኑን እድሜ አንድ ወይም ከዝያ በላይ የዕድገት እርከኖች አለደረሰም/ችም ነገር ግን *የወሰደ*የወሰደውን በሙሉ እና * ትንፋሽ በደቂቃ * የፈዘዘ/አእምሮውን የሳተ * ለ ________ቀናት፣ከ 7ቀን በላይ በየቀኑ የነበረ ትኩሳት * የጆሮ ፈሳሽ * የሚታይ ከባድ የሰውነት ክሳት * ህፃን *መድሃኒት ከተላመደ ቲቢ የቀድሞውን እድሜ ሁሉንም የዕድገት እርከኖች ደርሷል/ለች * ጊዜውን የጠበቀ * ስለ ፈሳሽ እንደመጀመሪያውበወሰደ ቁጥር የሚያስመልሰው ‘_______/ደቂቃ * የሚነጫነጭ/የሚወራጭ *ባለፉት 3 ወራት በኩፍኝ ተይዞ የነበረ፤የማጅራት መገተር/ የርግብግቢት ማበጥ ለ ________ቀናት > 6 ወር እድሜ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም ህመምተኛ ጋር የቅርብ

አስጊ ሁኔታ ወይም የወላጅ/አሳዳግ ስጋት አለ*ያልወሰደ ስለ ልጆች እድገት እንክብካቤ

ወ * ኮንቫልሽን የነበረው *ፈጣን አተነፋፈስ * የተሰረጎዱ ዓይኖች * መላ ሰውነትን ያደረስ የኩፍኝ ሽፍታ * የጆሮ ፈሳሽ /መግል *የሚሰረጎድ የእግሮች እብጠት ግንኙነት ያለው * ጊዜውን ያልጠበቀ በለፈው 6 ወር ውስጥ *መች መመለስ የባሰበት* ኮንቫልሽን አሁን አለው * ደካማ አጠጣጥ - ሳል/የተዝረከረከ አፍንጫ/የቀላ ዓይን * ከጆሮው ጀርባ ህመም *ሙዋክ < 11.5/ 11.5-<12.5/ >12.5 ሳ.ሜ *ከቲቢ ህመምተኛ (መድሃኒት የቀድሞውን እድሜ አንድ ወይም ከዝያ በላይ የዕድገት እርከኖች አለደረሰም/ሰችም * የወሰደ እንዳለባት



_____ . __ * ስትራይደር * የሆዱ ቆዳ ሲቆነጠጥ፤ * ዓይን አር/ ጥቁሩ ዓይኑ የነጣ ያለው እብጠት ካለው *የምግብ ፍላጎት ሙከራ ያለፈ/ያላለፈ ግንኙነት *ያልወሰደ

ዲሴ ዘግይቶ/ ብጣም ዘግይቶ የሚመለስ * አርዲቲ፣ፖዘቲቭ/ኔጋቲቭ/አልተስራም * የእጅ መዳፍ መገርጣት/በመጠኑ/ያልገርጣ እብጠት ወይም የሚያዥ ቁስል በብብት/አንገት * ያልጀመረ ያልታወቀ


አለው የለውም ________ _____ . __ *ለ ________ቀናት ; * ለ ________ቀናት < 6 ወር እድሜ * እናት: *14 ቀን እና ከዛ በላይ የቆየ ሳል * ያጠናቀቀ በለፈው 6 ወር ውስጥ * ስለ ምግብ የተሻለው









Count 0-24 months 25-59 months

ተቅማጥን በ ORS and zinc የታከሙ -------

DD ተቅማጥን ORS ብቻ የታከሙ ----

SDD

NDD

ጤና ኬላ የተቀናጀ ማህበረሰብ ተኮር የጨቅላ ሕፃናት

ህክምናና እንክብካቤ መዝገብ( ከሁለት ወር ዕድሜ በታች የሆኑ )

ክልል ዞን / ክፍለ ከተማ / ወረዳ የጤና ተቋሙ ስም የተጀመረበት ቀን ያልቀበት ቀን

የተቀናጀ ማህበረሰብ ተኮር የጨቅላ ሕፃናት ህክምናና እንክብካቤ መዝገብ( ከሁለት ወር ዕድሜ በታች የሆኑ )

mmRÃ

k5 ›mT b¬C HÉÂT mZgBN bTKKL lmÑ§T kz!H b¬C ytzrz„TN n_ïC b_N”q& mmLkT xSf§g! nWÝÝ YH mZgB Sl HÉÂT HKMÂÂ XNKBµb@ y_‰T dr© lmgNzB y¸ÃSCL -”¸ mr© MN+ çñ XNÄ!ÃglGL çñ ytzUj nWÝÝ SlçnM b_‰TÂ btà§ mNgD mä§T YñRb¬LÝÝ

1 bz!H mZgB WS_ bÑl# mSmR ¬_é ¨GDM ytzrUW ú_N /row/ lxND b>t¾ mr© mmZgb!Ã XNÄ!çN tdR¯ ytzUj nWÝÝ kF BlÖ bR:S mLK ytqm-W ¨GDM mSmR XNd SM½ :D»½ ò¬½ KBdT½ wzt lmmZgB ytmdb ï¬ nWÝÝ

2 xNÄND ú_ñC bn-BÈB mSméC ytkfl# ÂcWÝÝ lMúl@ ymjmRÃW Ì*¸ ú_N /column/ bz!H ›YnT mSmR tkFl*LÝÝ k§Y qN s!ÉF k¬C t‰ q$$$_R YÉÍLÝÝ btmúúlY mLk# b2¾W Ì*¸ ú_N SM k§Y xD‰š k¬C YÉÍLÝÝ b3¾W Ì¸ ú_N :D» k§Y ò¬ k¬C½ b 4¾W Ì¸ ú_N KBdT k§Y ysWnT ÑqT k¬C mÉF xlbTÝÝ

3 HÉn# ymÈbT êÂ y-@Â CGR b¸lW Ì¸ ú_N ýS_ w§J Lj*N XND¬mÈ ÃSgdÄT êÂ y-@Â CGR bGL} mÉF xlbTÝÝ

4 mZgb# §Y ktÉûT yb>¬ MLKèC WS_ HÉn# §Y ytgßWN b¥KbB¿ KFT ï¬ãC §Y bmÉF wYM y‰YT MLKT √ b¥Sqm_ mZgb#N btà§ mNgD mÑ§T ÃSfLULÝÝ

5 ywsN>WN SÃ» wYM SÃ»ãC½ ys->WN HKMÂ mD¦n!T½¶fR µL> yt§kbT ï¬½ ÃdrG>WN KTTL¿ bKTTL wQT ytgßW yHKMÂ W-@T lÃNÄNÇ bts-#T tgb! ú_ñC bGL}Â btà§ mmZgB ÃSfLULÝÝ

6 HÉn#N bM¬k!¸bT wQT ¥N¾WM Wún@ k¥DrG> bðT ¥lTM yb>¬ SÃ» kmS-T> bðT½ mD¦n!T kmS-T> wYM ¶fR k¥DrG> bðT½ y¸ÃSfLgWN KTTL km-wsN> bðT ytgß#TN ykbB>ÃcWN yÉF>ÃcWN wYM y‰YT mLKT ÃdRG>ÆcWN mr©WC bÑl# bm-qM TKKl¾ Wún@ §Y XNDTdR¹! ÃGZšLÝÝ

7 HKMÂ¼XNKBµb@ ls-šcW HÉÂT bÑl# KTTL ¥DrG l!¬lF ymYgÆ tGÆR nWÝÝ YHN ¥DrG> ytà§Â ÃLtö‰r- HKMÂ mS-T ÃSCLšLÝÝ bt=¥rM y_rT>N W-@T bGL} l¥YT ÃSCLšLÝÝ

8 የተገኘው የጤና ችግር ስያሜ በESV-ICD11 መሰረት ስምና ኮድ ተለይቶ ይጻፍ፡፡

ቀን ስም ዕድሜ በሳምንት ክብደት በኪ.ግ ጨቅላዉ የመጣበትን ዋና

የጤና ችግር

ሲወለድ ያለዉ ከብደት( እሰከ 7 ቀን ዕድሜ ብቻ ) የጨቅላዉ ህመም ምልክቶች በተገኙበት ሁሉ ላይ አክብቢ ወይም ፃፊ የጨቅላዉ ህመም ምልክቶች በተገኙበት

ሁሉ ላይ አክብቢ ወይም ፃፊ ሌላ የጤና ችግር የተገኘው የጤና ችግር ስያሜየተሠጠው ህክምና የክትትል ቀን የተገኘው የጤና ችግር ስያሜ በESV-ICD11 መሰረት

አስተያየትተ.ቁ

አድራሻ ፆታ የአተነፋፈስ ችግር/ጨቅላዉ ወደያዉኑ

እንደተወለደየክትባት ሁኔታ

የተሠጠው መድሃኒት አወሳሰድ እናትን ማማከርእሪፈር ከተባለ የተላከበት ተቋም ስም የተሠጠው አጭር

የቀጠሮ ቀን ውጤት የበሽታው ስም ኮድ(ቀበሌ /ንዑስ ቀበሌ) የሰውነት ሙቀት ተጸንሶ የቆየበት ግዜ ከባድ በሽታ/የባክቴሪያ ኢንፌክሽን ተቅማጥ ኤች.አይ.ቪ ኤድ የአመጋገብ ችግር/ዝቅተኛ ክብደት የተላከበት ተቋም ስም

ትንፋሽ ያሌለዉ ከ1500 ግራም ያነሰ ከኮንቨልሽን ነበረዉ/አለዉ አለው የለውም ጡት ይጠባል/አይጠባም አለው የለውም ________ _____ . __ የሚያጣጥር ከ1500 ግራም - ‹2500 ግራም ፍጹም የማይጠባ/በደንብ የማይጠባ *ለ ________ቀናት ; * እናት: በ24 ሰኣት ከ8 ግዜ ያነሰ ጡት የሚጠባ * ስለ ምግብ የተሻለው

በወር በኪ.ግ ደካማ አተነፋፈስ፣ ከ30በታች በደቂቃ 2500 ግራም እና ከዛ በላይ ትንፋሽ በደቂቃ-------፤ ፈጣን አተነፋፈስ * ደም የቀላቀለ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም አንዱ ጡት ሳያልቅ ወደ ሌላዉ የሚቀየርከባድ የደረት መሰረጎድ / የእምብረት መቅላት/መምገል ሲነካካ ብቻ እንቅስቃሴ የሚያደረግ * ህፃን ከጡት ሌላ ምግብ ወይም ፈሳሽ የሚወሰድ * ጊዜውን የጠበቀ * ስለ ፈሳሽ እንደመጀመሪያው

ሙቀት37.5 ዲ.ሴ ና ከዛበላይ/ከ35.5 ዲ.ሴ በታች/ሰዉነቱ ሲነካ የሚያተኩስ/የሚቀዘቅዝ ሲነካካም እንቅስቃሴ የማያደረግ ጨቅላ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም ሲያመዉ ቶሎ ቶሎ ና ለበለጠ ሰአት የማይጠባ * ስለ ልጆች እድገት እንክብካቤቀበሌ ወ ከ32 ሳምንት በታች መግል የቋጠረ የቆዳ ሽፍታ * የሚነጫነጭ/የሚወራጭ ክብደቱ ዝቅተኛ የሆነ/ያልሆነ * ጊዜውን ያልጠበቀ *መች መመለስ የባሰበት

ከ32-‹37 ሳምንት ሲነካካ ብቻ እንቅስቃሴ የሚያደረግ ጨቅላ * የተሰረጎዱ ዓይኖች የአፋ ዉስጥ ቁስለት /ትራሽ ያተገኘበት እንዳለባት ንዑስ ቀበሌ ሴ 37 ሳምነት እና ከዛ በላይ ሲነካካም እንቅስቃሴ የማያደረግ ጨቅላ * የሆዱ ቆዳ ሲቆነጠጥ፤ ጡት በደንብ አልጎረሰም * ያቋረጠ የሞተ

_____ . __ የአይን/ቆዳ ቢቻ ቢጫነት /የእጅ እና የእግር ቢጫነት ዘግይቶ/ ብጣም ዘግይቶ የሚመለስ ጡት በደንብ አይሰብም

ዲሴ ዕድሜ ከ24 ሰኣት በታች/ከ14 ቀን በላይ * ያልጀመረ ያልታወቀ


በወር በኪ.ግ ደካማ አተነፋፈስ፣ ከ30በታች በደቂቃ 2500 ግራም እና ከዛ በላይ ትንፋሽ በደቂቃ-------፤ ፈጣን አተነፋፈስ * ደም የቀላቀለ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም አንዱ ጡት ሳያልቅ ወደ ሌላዉ የሚቀየርከባድ የደረት መሰረጎድ / የእምብረት መቅላት/መምገል ሲነካካ ብቻ እንቅስቃሴ የሚያደረግ * ህፃን ከጡት ሌላ ምግብ ወይም ፈሳሽ የሚወሰድ * ጊዜውን የጠበቀ * ስለ ፈሳሽ እንደመጀመሪያውሙቀት37.5 ዲ.ሴ ና ከዛበላይ/ከ35.5 ዲ.ሴ በታች/ሰዉነቱ ሲነካ የሚያተኩስ/የሚቀዘቅዝ ሲነካካም እንቅስቃሴ የማያደረግ ጨቅላ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም ሲያመዉ ቶሎ ቶሎ ና ለበለጠ ሰአት የማይጠባ * ስለ ልጆች እድገት እንክብካቤ

ቀበሌ ወ ከ32 ሳምንት በታች መግል የቋጠረ የቆዳ ሽፍታ * የሚነጫነጭ/የሚወራጭ ክብደቱ ዝቅተኛ የሆነ/ያልሆነ * ጊዜውን ያልጠበቀ *መች መመለስ የባሰበትከ32-‹37 ሳምንት ሲነካካ ብቻ እንቅስቃሴ የሚያደረግ ጨቅላ * የተሰረጎዱ ዓይኖች የአፋ ዉስጥ ቁስለት /ትራሽ ያተገኘበት እንዳለባት

ንዑስ ቀበሌ ሴ 37 ሳምነት እና ከዛ በላይ ሲነካካም እንቅስቃሴ የማያደረግ ጨቅላ * የሆዱ ቆዳ ሲቆነጠጥ፤ ጡት በደንብ አልጎረሰም * ያቋረጠ የሞተ_____ . __ የአይን/ቆዳ ቢቻ ቢጫነት /የእጅ እና የእግር ቢጫነት ዘግይቶ/ ብጣም ዘግይቶ የሚመለስ ጡት በደንብ አይሰብም






_____ . __ የአይን/ቆዳ ቢቻ ቢጫነት /የእጅ እና የእግር ቢጫነት ዘግይቶ/ ብጣም ዘግይቶ የሚመለስ ጡት በደንብ አይሰብም






_____ . __ የአይን/ቆዳ ቢቻ ቢጫነት /የእጅ እና የእግር ቢጫነት ዘግይቶ/ ብጣም ዘግይቶ የሚመለስ ጡት በደንብ አይሰብምዲሴ ዕድሜ ከ24 ሰኣት በታች/ከ14 ቀን በላይ * ያልጀመረ ያልታወቀ


በወር በኪ.ግ ደካማ አተነፋፈስ፣ ከ30በታች በደቂቃ 2500 ግራም እና ከዛ በላይ ትንፋሽ በደቂቃ-------፤ ፈጣን አተነፋፈስ * ደም የቀላቀለ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም አንዱ ጡት ሳያልቅ ወደ ሌላዉ የሚቀየርከባድ የደረት መሰረጎድ / የእምብረት መቅላት/መምገል ሲነካካ ብቻ እንቅስቃሴ የሚያደረግ * ህፃን ከጡት ሌላ ምግብ ወይም ፈሳሽ የሚወሰድ * ጊዜውን የጠበቀ * ስለ ፈሳሽ እንደመጀመሪያውሙቀት37.5 ዲ.ሴ ና ከዛበላይ/ከ35.5 ዲ.ሴ በታች/ሰዉነቱ ሲነካ የሚያተኩስ/የሚቀዘቅዝ ሲነካካም እንቅስቃሴ የማያደረግ ጨቅላ ፖዘቲቭ/ኔጌቲቭ/አይታወቅም ሲያመዉ ቶሎ ቶሎ ና ለበለጠ ሰአት የማይጠባ * ስለ ልጆች እድገት እንክብካቤ

ቀበሌ ወ ከ32 ሳምንት በታች መግል የቋጠረ የቆዳ ሽፍታ * የሚነጫነጭ/የሚወራጭ ክብደቱ ዝቅተኛ የሆነ/ያልሆነ * ጊዜውን ያልጠበቀ *መች መመለስ የባሰበትከ32-‹37 ሳምንት ሲነካካ ብቻ እንቅስቃሴ የሚያደረግ ጨቅላ * የተሰረጎዱ ዓይኖች የአፋ ዉስጥ ቁስለት /ትራሽ ያተገኘበት እንዳለባት

ንዑስ ቀበሌ ሴ 37 ሳምነት እና ከዛ በላይ ሲነካካም እንቅስቃሴ የማያደረግ ጨቅላ * የሆዱ ቆዳ ሲቆነጠጥ፤ ጡት በደንብ አልጎረሰም * ያቋረጠ የሞተ_____ . __ የአይን/ቆዳ ቢቻ ቢጫነት /የእጅ እና የእግር ቢጫነት ዘግይቶ/ ብጣም ዘግይቶ የሚመለስ ጡት በደንብ አይሰብም

ዲሴ ዕድሜ ከ24 ሰኣት በታች/ከ14 ቀን በላይ * ያልጀመረ ያልታወቀቁጥር ቁጥርእጅግ በጣም ከባደ በሽታ----------- ለሳምባ ምች የታከሙ ------------------- በጣም ከባደ በሽታ------------ ተቅማጥን በ ORS and zinc የታከሙ -------------------

የተወሰነ የባክቴሪያ ኢንፌክሽን----------- ተቅማጥን ORS ብቻ የታከሙ -------------------

የሳንምባ ምች ------------

የተቀናጀ ማህበረሰብ ተኮር የጨቅላ ሕፃናት ህክምናና ክብካቤ መዝገብ (ከሁለት ወር ዕድሜ በታች የሆኑ)


Health Post Integrated PC-NTD Elimination/

Control Program Treatment Register

MDA register Col. Variable Description 1 Name in full (individual,

father, grandfather)Write the full name of the client

2 Sex Write M for male F for female

3 Year of treatment Year of treatment

4 Age Write the age in year or month if the client is below a year and add “M”

5 Ivermectin tab Write the # of Ivermectin tablets swallowed for round 1 or the reason for not taking the drug.

6 Write the # of Ivermectin tablets swallowed for round 2 or the reason for not taking the drug.

7 Albendazole tablet Write the # of Albendazole tablets swallowed or the reason for not taking the drug.

8 Praziquentale tab Write the # of Praziquentale tablets swallowed or the reason for not taking the drug.

9 Mebendazole tablet Write the # of Mebendazole tablets swallowed for round 1 or the reason for not taking the drug.

10 Write the # of mebendazole tablets swallowed for round 1 or the reason for not taking the drug.

11 Zithromax Tab Write the # of zitromax tablets swallowed or the reason for not taking the drug.

12 Zithromax Syrup Write the # of zitromax bottle dispensed or the reason for not taking the drug.

13 TEO Write the # of tetracycline ointment tube dispensed or the reason for not taking the drug.

14 Person Treated For (1,2,3,4,5,6)

1- Oncho 2- LF 3- STH

15 Adverse effect(Yes/No) Write “yes” if the cleint gets adverse effect or “No” if not happenned

16 If yes,For Which Drug(1,2,3,4,5,6)

1. Ivermectin

2. Albendazole

3. Prazequentale

4.Mebendazole

5. Zithromax

6. TEO (Tetracycline ointment)

17 TT (✓) screeen for Trachoma trachiasis case, and Tick (✓) if screening done

18 lymphedema (✓) Screen cases who has symptoms for leg swelling, and Tick (✓) if screening done

19 cutaneous leishmaniasis (✓) Screen cases who has symptoms for cutaneous leishmaniasis, and Tick (✓) if screening done

20 hydrocels (✓) Screen patients who has scrotal swelling, and Tick (✓) if screening done

21 Leprosy (✓) Screen the cleints who has skin rash and loss sensation, and Tick (✓) if screening done

22 Remark (✓) Write comment or remark, and Tick (✓) if screening done

INSTRUCTIONS FOR INTEGRATED PC-NTD ELIMINATION/ CONTROL PROGRAM TREATMENT REGISTER AT HEALTH POST

Location information to be completed at top of register:

Household index registerColumn Description

1 Houshold Name

2 Write sex of the client

3 Write age of the client

4 Write theHH Identification no/ Family Folder

5 Write the family size in 2014 year





4- SCH 5- Trachoma 6- scabies

Sn. Houshold NameSex

(M/F)Age HH Identification no/ Family Folder

Familiy size

2014 2015 2016 2017 2018

(1) (2) (3) (4) (5) (6) (7) (8) (9)

Total

Houshold Index Register

HH Identification No: …………………………….

S.NName in full (individual,

father, grandfather)Sex

(M/F)Year of Rx

Age (Mo/Yr)

Dosage given by Treatment year

Person Treated For (1,2,3,4,5,6)

Adverse event Screening

RemarkIvermectine

tab-1 Albenda-zole-2

praziquen-tale-3

Mebenda-zole-4 zitromax-5

Tetraxy-cline eye

ointment-6

ADR (Yes/No)

If yes,For Which Drug(1,2,3,4,5,6)

TTLymphede-

ma Cutaneous

leishmaniasisHydrocele Leprosy

(R1) (R2) (R1) (R2) TAB POS

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22)

2014

2015

2016

2017

2018

2014

2015

2016

2017

2018

2014

2015

2016

2017

2018

2014

2015

2016

2017

2018

2014

2015

2016

2017

2018

2014

2015

2016

2017

2018

Keys:

Reason for not Treated at each drug colimns: AB- Absentees R - Refusals S - Sick PW - Pregnant women C - Children less than 5 years BF - Breastfeeding women < 7 days D-Death

Person Treated For:(Col. 14) 1- Oncho 2 - LF 3 - STH 4 - SCH 5 - Trachoma 6-Scabies

For which drug (Col. 16) 1-IVM 2- ALB 3 - MBD 4- PZQ 5 -Zitromax 6-TEO

INTEGRATED PC-NTD ELIMINATION/ CONTROL PROGRAM TREATMENT REGISTER AT HEALTH POST


Health Post Diseases Tally

Disease Name (ESV-ICD 11)Female Male

<1 yr 1 - 4 yrs 5 - 14 yrs 15 – 29 yrs 30 – 64 yrs >=65 yrs <1 yr 1 - 4 yrs 5 - 14 yrs 15 – 29 yrs 30 – 64 yrs >=65 yrs Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count Tally Count

Normal labor

Labor complications

Maternal sepsis

Mastitis

Postpartum haemorrhage

Fistula

Uterine prolapse

Cervical Cancer (identification and referral)

Umblical Cord infection

Congenital anomalies (identification and referral)

Neonatal and childhood ilnesses (Neonatal sepsis)

Neonatal and childhood ilnesses (Pneumonia)

Neonatal and childhood ilnesses (Diarrhea)

Neonatal and childhood ilnesses ( Measles)

Worm manifestations in chidren

Vitamin deficiency diseases

Child abuses (identification and treatment)

Vaccinine preventable diseases

Severe acute malnutrition (SAM )

Moderate acute malnutrition (MAM)

Pharyngitis

Tonsillitis

Sinusitis

Abortion or post abortion complications

Menstrual problems and irregularities

Malnutrition in preganacy

Teenage pregnancy

Pre Eclampsia and Eclampsia

Iodine defficiency diseases (Goiter)

Gender Based Violance (GBV)

Anaemia

STIs

HIV/AIDS


Health Post Diseases TallyRDT (+) Uncomplicated malaria

Severe complicated malaria

TB Suspect case

Breast cancer (Screening)

Hypertension (screening)

Type 2 Diabetes Milletus (Screening)

Mild Asthma

Severe Asthma

Poisoning

Cataract (Screening)

Vision Impairment or Refractory Error (screening)

Screening for Blindness

Glucoma screening

Mental disorder

Neurological disorder

Drug and alchol abuse disorders

Eye Infection

Laceration

Wound

Fracture (referral)

Dislocation (referral)

Superficial abscess (referral)

Foreign body in the ear

Foreign body in the air way

Choking

Acute musculoskeletal injury

Rabies (referral)

Anthrax (referral)

Brucellosis (referral)

Syphilis in preogrnancy (Screening)

Gonorrhoea

Chlamydia

Trichomoniasis

Pelvic Inflammatory Disease (PID)

Urinary Tract Infection (UTI)

Soil Transmitted Helminths (in pregnancy)

Scabice

Burn

Abscess

Acute urinary retension

Dental caries

Dental abscess

Periodontal abscess

Oro-facial infection

Nasal obstruction

Eair obstruction

Breathing difficulty

Shock

Altered mental status

Trachoma

Diarrhoea (bloody)

Diarrhoea (watery)

Other oro-fecal infections

Constipation

Pneumonia

Acute Bronchitis

Lymphatic filariasis

Onchocerciasis

Trachoma

Schistosomiasis

Guinea-worm Elimination



Health Post Service Delivery Tally

Health Post Monthly Service Delivery Tally

Health Post Service Delivery Tally SheetWoreda:______________ Health Post: ______________ Year: ____________ Month:____________

I Reproductive, Maternal, Neonatal, and Child Health

Write Household NumberTotal CountContraceptive acceptance rate

1 Contraceptives Methods 10-14 yrs Count 15-19 yrs Count 20 - 24 yrs Count 25 -29 yrs Count 30 -49 yrs Count

1.1 New acceptors by Method

1.1.1 Oral contraceptives

1.1.2 Injectable

1.1.3 Implants

1.1.4 IUCD

1.1.5 Others

Total New Acceptors Count for Age

1.2 Repeat acceptors by Method

1.2.1 Oral contraceptives

1.2.2 Injectable

1.2.3 Implants

1.2.4 IUCD

1.2.5 Others

Total Repeat acceptors Count for Age

S.No Activity Write Household Number Count

3 Births attended by skilled health personnel

3.1 Total Number of births attended by level IV HEW at Health post

3.1.1 Number of still births

3.1.2 Number of Live births

3.2 Community birth and death notification

3.2.1 Community birth notification

3.2.2 Community death notification

4 Early Postnatal Care Coverage

4.1 Number of postnatal visits within 7 days of delivery

4.1.1 Early first postnatal care attendances 0-24 hrs (1 days)

4.1.2 Early first postnatal care attendances 25-48 hrs (1-2 days)

4.1.3 Early first postnatal care attendances49-72 hrs (2-3 days)

4.1.4 Early first postnatal care attendances 73hrs-7 days ( 4- 7 days)

4.2 Number of Maternal Deaths in the community

4.2.1. Total number of maternal deaths in the community

4.2.2 Number of maternal deaths at home

4.2.3 Number of maternal deaths on the way to health facility

4.2.4 Number of maternal deaths at health post


S.No Activity

Write Household Number Count5 Immunization

5.1 EPI(Immunization Coverages)

5.1.1 Number of Live births who receive a HepB-Birth dose(BD) within 24 hours after birth

5.1.2Number of Live births who receive a HepB-Birth dose(BD) 24 hours - 14 days after birth

5.1.3 Number of children under one year of age who have received BCG vaccine

5.1.4Number of children under one year of age who have received first dose of pentavalent vaccine

5.1.5Number of children under one year of age who have received third dose of pentavalent vaccine

5.1.6Number of children under one year of age who have received first dose of pneumococcal vaccine

5.1.7Number of children under one year of age who have received third dose of pneumococcal vaccine

5.1.8Number of children under one year of age who have received first dose of oral polio vaccine

5.1.9Number of children under one year of age who have received third dose of oral polio vaccine

5.1.10Number of children under one year of age who have received one dose of inactivated polio vaccine


S.No ActivityWrite Household Number Count

5.1 EPI(Immunization Coverages)

5.1.11 Number of children under one year of age who have received first dose of Rotavirus vaccine

5.1.12Number of children under one year of age who have received second dose of Rotavirus vaccine

5.1.13 Number of children under one year of age who have received first dose of Measles vaccine

5.1.14 Number of children received all vaccine doses before 1st birthday

5.1.15Number of children for 15-23 months of age who have received Measles second dose vaccine

5.1.16 Number of Infants whose mothers had protective doses of TT(Td) against NNT (PAB)

5.1.17Number of girls 14 year of age who have received first dose of human papilloma virus vaccine

5.1.18Number of girls 14 years of age who have received second dose of human papilloma virus vaccine in 6 months interval from the first dose


S.No ActivityCount

5.2 TT Vaccination Write Household Number

5.2.1 Number of women who have received TD1 vaccination





5.3 Vaccine wastage rate Put ‘/’ tally for doses opened/damaged/expired Count

5.3.1 HepB-Birth doses given (all ages) / doses opened / dose damaged/dose expired / / / / / /

5.3.2 BCG doses given (all ages) / doses opened / dose damaged/dose expired

5.3.3 Pentavalent (DPT-HepB-Hib) doses given (all ages) / doses opened , dose damaged/dose expired / / / / / /

5.3.4 Pneumococcal conjugated vaccine doses give (all ages)/doses opened , dose damaged/dose expired / / / / / /

5.3.5 Rota doses give (all ages)/doses opened /dose damaged/dose expired / / / / / /

5.3.6 Polio doses given (all ages) / doses opened /dose damaged/dose expired / / / / / /

5.3.7 Measles doses given (all ages) / doses opened/dose damaged/dose expired / / / / / /

5.3.8 Td doses given / doses opened/dose damaged/dose expired / / / / / /

5.3.9 IPV doses given / doses opened /dose damaged/dose expired / / / / / /

5.3.10 HPV doses given /doses opened/dose damaged/dose expired / / / / / /


S.No Activity Write Household Number

Total Count6 Child Health

6.1 Early neonatal death at community In the first 24 hrs of life Count Between 1-7 days of life Count Between 7-28 days of life Count

6.1.1 Neonatal death at home

6.1.2 Neonatal death on the way to health facility

6.1.3 Neonatal death at health post

6.1.4 Total Neontal death count by time period

6.1.5 Total number of live births in the kebele

6.2 Under-five children with pneumonia received antibiotic treatment

6.2.1 Number of under 5 children treated for pneumonia

6.3 Sick Young infant treated for Newborn infection

6.3.1 Number of sick young infants 0-2 months treated for critical illness (Refered)

6.3.2 Number of sick young infants 0-2 months treated for VSD/ sepsis (Refered)

6.3.3 Number of sick young infants 0-2 months treated for Pneumonia

6.3.4 Number of sick young infants 0-2 months treated for local bacterial infection(LBI)

6.4 Proportion of children who are treated for Diarrhea Treated by ORS & Zinc Count Treated by ORS only Count

6.4.1 Number of children who are treated for Diarrhea

6.5 Newborns that received at least one dose of CHX to the cord on the first day after birth

6.5.1 Newborns that received at least one dose of CHX to the cord on the first day after birth



6.6 Percentage of Low birth weight newborns

6.6.1 Number of live-born babies with birth weight less than 2,500 g

6.6.2 Total number of live births weighed

6.7. Promotion of GMP participation among children under 2 years Age: 0 - 5 Months Count Age: 6 - 23 Months Count Total count

6.7.1 Number of children less than 2 years weighted during GMP session

6.7.2Number of weights recorded with moderate malnutrition, by age (Z-score between -2 and -3) : moderate Underweight

6.7.3. Number of weights recorded with severe malnutrition, by age (Z-score below (-3) : Severely underweight

6.8 Children aged <5 years screened for acute malnutrition Age: 0 – 5 Months Count Age: 6 - 59 Months Count Total count

6.8.1 Total Number of children < 5 years screened for acute malnutrition

6.8.2 Number of weights recorded with moderate acute malnutrition

6.8.3 Number of weights recorded with severe acute malnutrition




6.9Treatment outcome for management of severe acute malnutrition in children 6-59 months(OTP )

6.9.1 Treatment outcome for management of SAM in children 6-59months

6.9.1.1 Number of children Cured

6.9.1.2 Number of children died

6.9.1.3 Number of children defaulted

6.9.1.4 Number of children -non-respondent

6.9.1.5 Number of children transferred out

Total number of children who exit from severe acute malnutrition treatment(OTP)

6.9.8Total number of children with SAM ad-mitted to TFP(OTP) during the reporting period


S.No Activity Write Household Number Total Count

6.10 Children aged 6-59 months who received vitamin A supplementation First Dose Count Second Dose Count

6.10.1 Total number of children aged 6-59 months who received Vitamin A supplementation

6.10.1.1 Age: 6 – 11 months

6.10.1.2 Age: 12 – 59 Months

6.10.2 Total number of children aged 24 – 59 months dewormed

7.1 Proportion of pregnant and lactating women (PLW) screened for acute malnutrition MUAC < 23 cm Count MUAC >= to 23cm Count

7.1.1 Total number of PLW screened for acute malnutrition

7.2 Proportion of pregnant women received iron and folic acid (IFA) supplements at least 90 plus 10-14 years Count 15-19 years Count >= 20 years Count

7.2.1 Total number of Pregnant women received IFA at least 90 plus

7.2.2 Number of pregnant women De-wormed

Adolescent nutrition Service Tally Woreda________ Health facility____________ Year______________ Month_______________

S.no Service

Age

10-14 15-19 Total countMale Female Male Female

7.3 Nutritional screening

7.3.1 NornalTally

Count

7.3.2 Under weightTally

Count

7.3.3 OverweightTally

Count

7.3.4 ObeseTally

Count

7.3.5 Very obeseTally

Count

Total Count

7.4 Deworming

7.4.1 Dose 1Count

Tally

7.4.2 Dose 2Count

Tally

Total count

7.5 Iron Folic acid(IFA)

7.5.1

Adolescent received IFA tablets for four consecutive weeks in the reporting period

Tally

Count

Total count

Health Post Service Delivery Tally Sheet



8 Malaria positivity rate

8.1 Number of slides or RDT positive for malaria

8.1.1 < 5 years :Male

8.1.2 :Female

8.1.3 5-14years : Male

8.1.4 :Female

8.1.5 >=15 years :Male

8.1.6 :Female

8.2 Total number of slides or RDT performed for malaria diagnosis

8.2.1 P. falciparum

8.2.2 P.Vivax

8.2.3 Malaria with pregnancy

8.2.4 Malaria with Travel History

8.2.5 Total number of people with fever

8.3 Proportion of targeted HH covered with LLITN in the last 12 month

8.3.1 Number of targeted HH recived at least one LLITN in the last 12 month

8.3.2. Number of HHs that need LLITN in the last 12 month



9 Outpatient attendance per capita

Male Count Female Count

9.1 Number of outpatient visits

9.1.1 OPD Visits < 5:

9.1.2 OPD visits 5-9:

9.1.3 OPD visits 11-19




9.1.7 OPD visits >=66


S.No Activity

Days of the reporting month(Write 1 if the drug is available for the day,if not write 0)

Write 1 if drug

available for 30 days / whenever needed ;if

not write 0

10 Essential drug availability

Months21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 10 11 13 14 15 16 17 18 19 20

10.1 Amoxicillin dispersable tablet

10.2 Oral Rehydration Salts

10.3 Zinc dispersible tablet

10.4 Gentamycin Sulphate injection

10.5 Medroxyprogesterone Injection

10.6 Arthmeter + Lumfanthrine (Coartem) tablet (any packing)

10.7 Ferrous sulphate + folic acid

10.8 Albendazole tablet/suspension

11 Evidence Based Decision Making

11.1 Data quality assurance (LQAS) Score

11.2 Integrated Supportive supervision

11.3 Number of supervisory visits with written feedback received

11.4 Number supervisory visits expected in the reporting period

HSTP II HMIS TOOLSHOSPITAL, HEATH CENTER AND HEALTH POST

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