Health Facility Routine Monthly Report Template

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Routine Monthly Report Health Facility:
Payam _________County __________
Report Month/Year:
By _________________________________________
PART 1 / DATA ELEMENT
NUMBER
COMMENTS
1. Curative consultation under 5 male
2. Curative consultation under 5 female
3. Curative consultation 5 years and older male
4. Curative consultation 5 years and older female
st
5. Antenatal client 1
visit
th
6. Antenatal client 4
or more visit
nd
7. Antenatal client IPT 2
dose
8. Family Planning new user
9. Delivery in facility by Skilled Birth Attendant
10. Delivery in facility by TBA, MCHW, CHW, Community or Village Midwife
11. Delivery in the community
12. Delivery referred
13. Live birth in facility
st
14. Post natal client 1
visit
15. Malaria uncomplicated clinically diagnosed under 5 years
16. Malaria uncomplicated confirmed under 5 years
17. Malaria severe under 5 years
18. Malaria uncomplicated 5 years and older
19. Malaria severe 5 years and older
20. Pneumonia presumed under 5 years
21. Diarrhea treated with ORS under 5 years
22. Diarrhea all under 5 years
23. Vitamin A supplement 6-59 months (dose)
24. Vitamin A supplementation new mother
25. Insecticide treated net to under 5 years
26. Insecticide treated net to antenatal client
27. MUAC <115 mm under 5 years
28. MUAC <125 mm under 5 years
29. Death in facility all
30. Death in facility under 5 years
31. Death in facility maternal
32. TB Patient suspected
33. TB patient referred to the TB Management Unit
34. Payam outbreaks detected by the Health Facility
35. Payam outbreaks investigated by the Health Facility 48h after detection
36. Condoms distributed by the facility
37. VCT client seen
38. VCT client tested for HIV – new
39. VCT client tested HIV positive – new
40. VCT client who collects test result
41. Antenatal client tested for HIV
42. Antenatal client who collects test result
43. Antenatal client tested HIV positive – new
44. Antenatal client HIV positive given PMTCT –.new
45. HIV positive patient eligible for ART registered.- new
46. HIV positive patient who receives ART – new
47. Caesarian section done
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Routine Monthly Report Health Facility:
Payam _________County __________
Report Month/Year:
By _________________________________________
PART 1 / DATA ELEMENT
NUMBER
COMMENTS
1. Curative consultation under 5 male
2. Curative consultation under 5 female
3. Curative consultation 5 years and older male
4. Curative consultation 5 years and older female
st
5. Antenatal client 1
visit
th
6. Antenatal client 4
or more visit
nd
7. Antenatal client IPT 2
dose
8. Family Planning new user
9. Delivery in facility by Skilled Birth Attendant
10. Delivery in facility by TBA, MCHW, CHW, Community or Village Midwife
11. Delivery in the community
12. Delivery referred
13. Live birth in facility
st
14. Post natal client 1
visit
15. Malaria uncomplicated clinically diagnosed under 5 years
16. Malaria uncomplicated confirmed under 5 years
17. Malaria severe under 5 years
18. Malaria uncomplicated 5 years and older
19. Malaria severe 5 years and older
20. Pneumonia presumed under 5 years
21. Diarrhea treated with ORS under 5 years
22. Diarrhea all under 5 years
23. Vitamin A supplement 6-59 months (dose)
24. Vitamin A supplementation new mother
25. Insecticide treated net to under 5 years
26. Insecticide treated net to antenatal client
27. MUAC <115 mm under 5 years
28. MUAC <125 mm under 5 years
29. Death in facility all
30. Death in facility under 5 years
31. Death in facility maternal
32. TB Patient suspected
33. TB patient referred to the TB Management Unit
34. Payam outbreaks detected by the Health Facility
35. Payam outbreaks investigated by the Health Facility 48h after detection
36. Condoms distributed by the facility
37. VCT client seen
38. VCT client tested for HIV – new
39. VCT client tested HIV positive – new
40. VCT client who collects test result
41. Antenatal client tested for HIV
42. Antenatal client who collects test result
43. Antenatal client tested HIV positive – new
44. Antenatal client HIV positive given PMTCT –.new
45. HIV positive patient eligible for ART registered.- new
46. HIV positive patient who receives ART – new
47. Caesarian section done
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MONTHLY IDSR: Please indicate all suspected cases of any of the diseases quoted below.
Data Element
Number
Comments
1. Onchocerciasis; 2. STI; 3. Bilharzia; 4. Kala – Azar; 5. Lymphatic Filariasis; 6. Trypanosomiasis; 7. Rabies; 8. Plague; 9.
Leprosy; 10. Brucellosis; 11. Typhoid Fever.
PART 2
: EXPANDED PROGRAM OF IMMUNIZATION and PHARMACEUTICALS
Please note the EPI report refers to children
Children Under 1
Fixed
Outreach
Total
less than one year of age.
Vaccination Report
1.
BCG
2. OPV0
Tetanus Toxoid Vaccination
3. OPV1
Pregnant
Women 15-
4. OPV2
Women
45
5. OPV3
TT1
6. DPT1
TT2
7. DPT2
8. DPT3
TT3+
9. Measles
10. Yellow Fever
VACCINES/PHARMACEUTICALS
Opening
Received
issued/
Balance ( = left)
balance
discarded/ sent
to other centres
BCG
OPV
DPT
Tetanus Toxoid (TT)
Measles
Albendazole 200mg tabs
Amoxicillin 250mg caps/tabs
Artesunate +Amodiaquine (Adult: 6 tabs)
Artesunate +Amodiaquine (Child: 3 tabs)
Artesunate +Amodiaquine (Infant: 3 tabs)
Artesunate +Amodiaquine (Toddler: 3 tabs)
Ciprofloxacin 500mg tabs
Cotrimoxazole 480mg tabs
Ferrous Sulphate Folic Ac 200mg/0.25mg tabs
Metronidazole 200mg tabs
ORS
Paracetamol 500 mg
NOTE: Please write 0 (ZERO) if the health facility provides services but nobody came for this particular service during this
month period; if the health facility does not provide services please leave the space blank.
Date when the report was submitted
Signature
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