Health Centre /Clinic/Hospital
Integrated Adolescent and Youth
Health Service Register
Region
Zone/Subcity/Woreda
Health Facility Name
Begin Date
End Date
Instruction for Integrated Adolescent and Youth Health Service Register
Location information to be completed at front of the registry
Region
Zone/Sub-City /Woreda
Name of Health Facility
Register begin date
Register end date
Col.
Number
Write region name where the facility is located
Write Zone/Sub-City /Woreda name where the facility is located.
Write the name of the health facility where the service was provided.
Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)
Write the date of the last entry in the register, written as (EC) Day / Month / Year(DD/MM/YY)
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
3
Full Name
4
Age (YY)/Sex ( M/F)
Write full name of the adolescent or youth
Write the client age in years(YY) in the upper row , write the sex M= Male ;F=Female 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 ()
10
Referred from(write code)
Tick () if comprehensive counseling and information on AYH standard of service package is given , this includes menstrual hygiene management, HIV/AIDS,
pregnancy and CAC ,nutrition , etc
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
15
Targeted population category write
code
D. Prisoners
E. OVC
F. Children of PLHIV
G. Partners of PLHIV
H. Other MARPS
I. General population
Family Planning provided
16
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.*
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.
Write the abbreviate of Contraceptive method provided (record modern methods
only) as follows:
MaC- Male Condom
FeC- Female Condom
OC- Oral Contraceptive
18
Contraceptive Method provided
Inj- Injectable
EC- Emergency Contraception
Diaph-Diaphragm
IUCD- Intrauterine Contraceptive Device
Imp -Implant
19
HCG(Pregnancy) test
L=link or refer
If HCG test provided write code P for positive ; N for negative and N/A if not
applicable
Abortion care
20
Safe abortion care (√)
21
Post abortion care(√)
22
STI syndromic approach diagnosis
Tick (√) if client provided with safe abortion care
Tick(√) if client provided with post abortion care
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)
If the adolescent or youth use substance write code for
1. Alcohol use
23
Substance abuse
2. Drug use
3. Tobacco/Smoking
24
Psychotic problem
25
SGBV survivors
26
Non communicable illness screening
27
Menstrual hygiene management /
counselling and provision
28
Refer/link to other service
29
Providers name
30
Remark
4. Khat consume
5. Others
Write code 1. If Anxiety disorders; 2. Depression; 3. Psychosis; 4.Bipolar disorder;5. Behavioral disorders; 6.other (specify) white N/A if not applicable
Write Code for SGBV survivors if sustained 1 for physical violence 2. For psychological violence 3. For sexual violence 4. For more than one violence (specify) 5.
For all listed violence. N/A if not applicable
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
Write 1. if counselled on menstrual hygiene management 2. If counselled and provided material for menstrual hygiene
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
Write service providers name and signature
If provided additional service like condom …); appointment date or any other
concern
9
10
11 12 13
Count HIV
R
Marital Status col(7)
S-single
W-Widowd
D-Divorced
C-Cohabited
Reffered from Col(10)
1 .Youth Center
2. School
3 internal referral
4. other facility
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
16 17
Targeted population category col(15)
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
ND
18
20 21 22
23
Menstural hygiene 1= counselling 2. provided material
24
26
SGBV survivor (Write code)
STI write code
Post abortion care(√)
Safe abortion care (√)
Subtance abuse (write code)
HCG( Pregnancy test) result write (N/P/
NA)
19
25
27
28
29
Remark
30
Count
Test
NR
Contraceptive Method provided
(Write code)
Repeat acceptor (√)
15
New acceptor (√)
14
Provider’s name and signature
8
Refre to other service(write code)
7
Screened for non-communicable diseases
6
Abortion
care
Psychiatric problems (Write code)
5
Targeted population category
(write code)
4
Known HIV positives linked
from ART) (√)
3
HIV test status ( P/ N)
2
Got/
Ketena
HIV re-testing accepted (√)
1
Age
Woreda
(YY)/ Sex
/
(M/F)
Kebele
HIV testing accepted (√)
Full Name
Family planning
( if Applicable)
HIV testing
Refrred from(write code)
MRN
Marital status(Write code)
S.N
date of visit(DD/NMM/YY)
E.C.
Personal Identification
Comprehensive information and counselling on AYH Package (√)
Integrated Adolescent and Youth Health Service Register
New Rep
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)
Safe abortion 10-14
Post abortion 10-14
Safe abortion 15-19
Post abortion 15-19
Safe abortion 20-24
Post abortion 20-24
Safe abortion 25-29
Post abortion 25-29
substance use Col(23)
1.Alcohol use
2. Drug use
3. Tobacco/Smoking
4. Khat consume
5. Other
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 specify
5. All
6. NA
None Communicable
Refere to Other service Col(28)
illnes: Col(26)
1.ANC,Delivery ,PNC
1. BP for HPT
2.CAC
2.Blood and urine sugar 3.FP
for DM
4. One Stop Center
3.Check if HPV vaccinated 3.NCD Clinic
( age appropriate)
4.Mental Clinic
4 Breast examination
5.referred/Linked to other facility
6.Other specify
5. Other (Specify)
6. All