NHMIS MONTHLY SUMMARY FORM FOR HEALTH FACILITIES
(Version 2013)
Identification
Health Facility:
Political Ward:
LGA:
State:
Facility code:
Month:
Year:
Public:
Beds:
Private:
Health Facility Attendance
Male
1
Facility
Attendance
2
OPD Attendance
028d
29d 11 m
12 59 m
5-9
Yrs
Female
10 - 19
yrs
20
yrs+
028d
29d 11 m
12 59 m
5-9
Yrs
10 - 19
Yrs
20
yrs+
Total
Maternal Health (Ante & Post natal Care)
3 Antenatal attendance - total
4 Antenatal first visit before 20 weeks
5 Antenatal first visit 20 weeks or later
6 Antenatal first visit – total
th
7 Pregnant women that attended antenatal clinic for 4 visit during the month
8 ANC syphilis test done
9 ANC syphilis test positive
10 ANC syphilis case treated
11 Pregnant women who received malaria IPT1
12 Pregnant women who received malaria IPT2
13 Pregnant women who received LLIN
14 Pregnant women who received Haematinics’( IFAs - Iron and Folic Acid supplements)
15 Postnatal attendance – total
16 Postnatal clinic visits within 1 day of delivery
17 Postnatal clinic visits within 3 days of delivery
18 Postnatal clinic visits ≥7 days of delivery
Total
Maternal Health (Labour and Delivery)
19 Deliveries – total
20 Deliveries - SVD (Spontaneous Vaginal Delivery)
21 Deliveries - assisted
22 Deliveries - caesarean section
23 Deliveries - complications
24 Deliveries – preterm
25 Deliveries by HIV positive women
26 Live birth by HIV positive women
27 Deliveries amongst HIV positive women – Booked
28 Deliveries amongst HIV positive women – Unbooked
29 Deliveries monitored using a partograph
30 Deliveries taken by a skilled birth attendant
Total
Tetanus Toxoid (Women of child bearing age)
31 TT1
32 TT2
33 TT3
34 TT4
Pregnant
1
Non Pregnant
35 TT5
Pregnancy Outcome - Live Births
Male
36
Live Births
<2.5kg
Female
>2.5kg
<2.5kg
>2.5kg
Pregnancy Outcome - Still Births
37 Still births
38 Fresh still births (FSB)
39 Abortions (Induced)
40 Abortions (Total)
Total
Total
Pregnancy Outcome - Complications
41 Birth Asphyxia
42 Neonatal sepsis
Male
Female
Total
43 Neonatal tetanus
44 Neonatal jaundice
45 Low birth weight babies placed in KMC
46 Newborns with low birth weight discharged after KMC
Immunization
Antigen
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
< 1 year
Fixed
Outreach
Fixed
> 1 year
Outreach
Total
OPV 0 birth
Hep. B 0 birth
BCG
OPV 1
Hep. B 1
Penta. 1
DPT 1 (not when using Penta)
PCV 1
OPV 2
Hep. B 2
Penta. 2
DPT 2 (not when using Penta)
PCV 2
OPV 3
Penta. 3
DPT 3 (not when using Penta)
PCV 3
Measles 1
Fully Immunized < 1 year
Yellow Fever
Measles 2
Conjugate A CSM
Nutrition
69 Children 0-59 months weighed – total
70 Children 0-59 months weighing below the bottom line
71 Children 0-6 months reporting being exclusively breast fed
2
Male
Female
Total
72 Children 6-11 months given Vitamin A
73 Children 12-59 months given Vitamin A
74 Children 12-59 months given deworming medication
Children <5 years placed on treatment for severe acute
75 malnutrition (OTP & SC)
Children <5 years discharged (as healthy) from treatment for
76 severe acute malnutrition (Recovered)
77 Children admitted into CMAM Program
78 Children defaulted from CMAM Program
MALARIA PREVENTION (LLIN)
79
Total
Children under 5 years who received LLIN this month
IMCI
80 Diarrhoea new cases < 5 years
Male
Female
Total
Diarrhoea new cases < 5 years - given oral rehydration
81 preparations (low osmolar ORS)
Diarrhoea new cases < 5 years - given ORS and zinc
82 supplementation
83 Pneumonia new cases < 5 years
84 Pneumonia new cases < 5 years - given antibiotics (amoxyl DT)
85 Measles new cases < 5 years
Family Planning
86 Clients counselled
87 New family planning acceptors
88 FP clients accessing HCT services
89 Individual referred for FP services from HCT
90 Individual referred for FP services from ART (ART Refill)
91 Females aged 15 – 49 yrs using modern contraception
92 Persons given oral pills
93 Oral pill cycle (sachets) dispensed
94 Injectables given
95 IUCD inserted
96 Implants inserted
97 Sterilization
Male
Female
Total
98 Male Condoms distributed
99 Female Condoms distributed
100 Individual referred for FP services from PMTCT (HIV+ Pregnant Women)
Referrals
101 Referral in
102 Referral out
103 Malaria cases referred for further treatment
104 Malaria cases referred for adverse drug reaction
105 Women referred out for Pregnancy related complications
106 Women seen and referred for Obstetric Fistula (VVF & RVF)
Non-communicable diseases
107 Coronary heart disease new cases
108 Diabetes mellitus new cases
109 Hypertension new cases
Total
Male
3
Female
Total
110
111
112
113
114
115
Sickle cell disease new cases
Road traffic accident new cases
Home accident new cases
Snake bites new cases
Asthma new cases
Athritis new cases
Sexually transmitted infections
116
117
Total
STI treated new cases
Male Urethritis new cases
Laboratory
118 ANC anaemia test done
119 ANC anaemia test positive
120 ANC proteinuria test done
121 ANC proteinuria test positive
122 HIV rapid antibody test done
123 Sputum AFB - new diagnostic test done (incl. relapse)
124 Sputum AFB - new diagnostic test done (incl. relapse) - tested positive
Total
Inpatient
Total
125
126
127
Functional beds
Inpatient days – total
Inpatient discharges – total
Inpatient Admissions
128
Total
admissions
Male
028d
29d 11 m
12 59 m
5-9
Yrs
Female
10 - 19
Yrs
20
yrs+
028d
29d 11 m
12 59 m
5-9
Yrs
10 - 19
Yrs
20
yrs+
Pharmaceutical service
129 Prescriptions issued
130 Items dispensed
131 Antibiotics prescribed
132 Injectables prescribed
Total
Total
Adverse Drug Reaction
133 Adverse drug reactions (ADRs) reported following immunization
134 Adverse drug reactions (ADRs) reported following use of antiretrovirals
135 Adverse drug reactions (ADRs) reported following use of antimalarials
136
Antimalarials in the health facility with Mobile Authentification Service (scratch
card)
With Scratch
card
Without Scratch
card
Mortality
137
Total
Deaths
Male
028d
29d 11 m
12 59 m
5-9
Yrs
Female
10 - 19
Yrs
20
yrs+
Maternal Mortality
138
139
028d
29d 11 m
12 59 m
5-9
Yrs
10 - 19
Yrs
20
yrs+
Total
Total
Deaths of women related to pregnancy
Maternal Deaths Audited
4
140
Causes of
Maternal
death
Complications
Antepartum
haemorrhage
Pre/eclampsia
Post partum
haemorrhage
sepsis
Obstructed
labour
Abortion
Malaria
Anaemia
HIV
Others
Neonatal Deaths (Causes)
141
Causes of
Neonatal
deaths
Complications
Asphyxia
Sepsis
Prematurity
Neonatal
Tetanus
Diarrhoea
Congenital Malformation
Others
Under 5 Mortality(Causes)
142
Causes of
Under 5
Deaths
Complications
Diarrhoea
Malaria
Pneumonia
Malnutrition
Others
HIV, TB, Malaria and Integrated Services
HIV Counselling &
Testing
143
144
145
146
Male
<2
yrs
2-14
yrs
15 19 yrs
20 24 yrs
Female
25 49 yrs
<
2yrs
2-14
yrs
15 - 19
yrs
Male
< 15 yrs
50
yrs+
Total
HIV positive patients receiving cotrimoxazole prophylaxis
ART patients receiving ARV refill
Male
TB/HIV
160
161
Total
25 - 49
yrs
Female
< 15 yrs
>= 15 yrs
>= 15 yrs
SRH-HIV Integration
149 HCT clients provided with SRH/HIV integrated services
150 HCT clients referred for FP method
151 HCT clients screened for STIs
152 HCT clients treated for STIs
153 FP Clients provided with SRH/HIV Integrated service
154
155
156
157
158
159
20 - 24
yrs
Individuals HIV
counselled, tested and
received results
Individuals tested HIV
positive
Couples HIV counselled, tested &received results
Couples HIV counselled, tested &received results that are sero-discordant
HIV Care & Treatment
147
148
50
yrs+
Female
Total
Individuals clinically screened for TB
Individuals clinically screened for TB score 1+ (TB suspects)
Registered TB patients screened for HIV
Individuals started on TB treatment - HIV -negative
Individuals started on TB treatment - HIV Unknown
HIV positive clients attending HIV care and treatment services and receiving TB treatment
TB patients with HIV receiving ART
Co-infected persons on CPT
PMTCT - Mother
162 ANC women with previously known HIV status (At ANC)
163 Pregnant women who received HIV counseling, testing and received results at ANC
164 Pregnant women who received HIV counseling, testing and received results at L&D
165 Women who received HIV counseling, testing and received results at PNC
166 Partners of HIV positive pregnant women tested HIV negative
167 Partners of HIV positive pregnant women tested HIV positive
5
Total
Total
168
169
170
171
172
173
174
175
Partners of HIV negative pregnant women tested HIV positive
Partners of HIV negative pregnant women tested HIV negative
HIV positive pregnant women assessed for ART eligibility by either clinical stage or CD4
Pregnant HIV positive woman who received ARV prophylaxis for PMTCT(Triple)
Pregnant HIV positive woman who received ARV prophylaxis for PMTCT(SdNVP in labour + (AZT +3TC))
Pregnant HIV positive woman who received ARV prophylaxis for PMTCT(AZT)
Pregnant HIV positive woman who received ARV prophylaxis for PMTCT(SdNVP in labour only)
Pregnant HIV positive woman who received ARV prophylaxis for PMTCT (Total)
PMTCT - Infant
Male Female Total
176 Infants born to HIV infected women started on cotrimoxazole prophylaxis within 2 months
177 Infants born to HIV infected women started on cotrimoxazole prophylaxis 2 months & above
Infants born to HIV-infected women who received an HIV test within two months of birth -
178 (DNA-PCR)
Infants born to HIV-infected women who received an HIV test after two months of birth - (DNA-
179 PCR)
180 Infants born to HIV-infected women who received an HIV test at 18months-(HIV Rapid test)
181 Infant born to HIV-infected women who tested negative to HIV Rapid test at 18 months
182 HIV exposed infants breast feeding and receiving ARV prophylaxis
TB/LP
Male
0–4
yrs
5 -15
yrs
Female
> 15
yrs
0–4
yrs
Total
5 -15
yrs
> 15
yrs
183 TB cases (all forms) notified
184
185
186
187
188
189
TB cases successfully treated among all forms (cured and
completed)
Individual suspects screened for TB
DR-TB suspects tested for DR-TB
Confirmed DR-TB patients enrolled for treatment
Leprosy cases registered
Buruli Ulcer patients notified
Malaria Testing
< 5 years
≥ 5 years
Total
190 Persons with Fever
191 Persons presenting with fever and tested by RDT
192 Persons test positive for malaria by RDT
193 Persons presenting with fever and tested by Microscopy (for malaria parasites)
194
Persons tested positive for malaria by Microscopy
Malaria in Pregnancy
195
196
Total
Pregnant women with clinically diagnosed Malaria
Pregnant women with confirmed Malaria
Malaria Cases
197
198
199
< 5 years
≥ 5 years
< 5 years
≥ 5 years
Total
Persons with clinically diagnosed Malaria
Persons with confirmed uncomplicated Malaria
Persons with severe Malaria
Malaria Treatment
200 Persons with confirmed uncomplicated Malaria receiving ACT
201 Persons treated with ACT on the basis clinical diagnosis only
202 Persons with confirmed uncomplicated Malaria treated with other antimalarials
6
Total
VVF
Obstetric Fistula
203
204
205
206
207
RVF
VVF & RVF
Total
Women who reported leaking urine or feces
Women receiving surgery for fistula repair
Women receiving a first repair
Women receiving a second repair
Women discharged after fistula surgery
208 Women who had a closed and dry fistula at discharge
Commodity Availability
209 Stock out of any essential drug for 7 days consecutively in the last one month?
210 Stock out of vaccine supplies in the past one month?
211 Stock out of family planning commodities in the past one month?
212 Stock out of Female Condoms in the past one month?
213 Stock out of Implants in the past one month?
214 Stock out of Emergency Contraception in the past one month?
215 Stock out of Oxytocin in the past one month?
216 Stock out of Misoprostol in the past one month?
217 Stock out of Magnesium sulfate in the past one month?
218 Stock out of Injectable antibiotics in the past one month?
219 Stock out of Antenatal Corticosteroid (ANCS) in the past one month?
220 Stock out of Chlorhexidine in the past one month?
221 Stock out of Resuscitation Equipment in the past one month?
222 Stock out of Amoxicillin DT in the past one month?
223 Stock out of ORS / Zinc preparations in the past one month?
224 Stock out of IFAs in the past one month?
225 Stock out of ACTs for 7 days consecutively in the past one month?
226 Stock out of RDTs for 7 days consecutively in the past one month?
227 Stock out of SPs for 7 days consecutively in the past one month?
228 Stock out of LLINs for 7 days consecutively in the past one month?
229 Stock out of Antiretroviral Drugs in the past one month?
230 Stock out of HIV test kits for 7 days consecutively in the past one month?
231 Stock out of anti-TB drugs for 7 days consecutively in the past one month?
232 Stock out of CPT for 7 days consecutively in the past one month?
233 Stock out of INH for 7 days consecutively in the past one month?
Yes
No
N/A
Completed by: Designation:....................... Name: .............................. Signature: ............................
Date: ...........................
Verified by:
Date: ...........................
Designation:....................... Name: .............................. Signature: ............................
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