District Hospital Monthly HMIS Report
I. Identification and Important Communications
A) Report Identification
1. Facility Name
5. Year
2. Catchment Area Population
6. Month
3. Province
7. Sector
4. District
8. Cell
B) Report Approvals/Processing
1. Name of In-charge
5. Date received
2. Qualification
6. Name
3. Date of sent
7. Signature
4. Signature
8. Date entered in DHIS
II. Outpatient Consultations
A) Outpatient Morbidity summary table
Outpatient visits
M
B) Health insurance status of new cases
>=5 – 19 y
<5 yr
F
M
F
>=20 yr
M
F
New cases (NC)
Non-Paying New cases
Old cases
Number of Indigent new cases
C) Referrals
TOTAL
Insured (Mutuelle or other insurance members)
Total
D) Origin of outpatients
1.Referred to other levels
1. New cases from the catchment area (zone)
2. Counter referrals received
2. New cases (hors zone)
3. International patients (hors pays)
E) New cases of priority health problems in General
OPD
#
Diagnosis
ICD-10
1
Fever >=37.5 C (all causes)
2
Diarrhea with dehydration
A09.1
3
Diarrhea no dehydration
A09.2
4
Diarrhea bloody (dysentery)
A09.3
5
Food poisoning
A05
6
Ear infections
H65
7
Schistosomiasis
Ascarislumbricoides
Trichuristrichiura
Hookworm
Entamoeba
Giardia
Taenia
B65
B77
B79
B76
A06
A07
B68
B53.8
16
Malaria confirmed simple (not pregnant)
Malaria confirmed with minor digestive
symptoms (not pregnant)
Malaria (presumptive)
17
Herpes simplex infections
B00.9
18
Meningitis suspected
G03.9
19
Pneumonia
J18.9
20
Respiratory infections acute (ARI) other
J22, J06.9
8
9
10
11
12
13
14
15
B53.8.0
B54
Under 5 years
M
F
5 to 19 years
M
F
20 yrs and above
M
F
HMIS
District Hospital Monthly Report
E) New cases of priority health problems in General
OPD
#
Diagnosis
ICD-10
21
Gastritis and duodenitis
K29.9
22
Abscesses
L02.9
23
Ulcers of skin
L89
24
Skin Infection Scabies
B86
25
Skin Infection Fungal (mycoses) superficial
B36.9
26
Skin Infections Other
L??
27
Urinary Tract Infections
N39.0
28
Anemia (confirmed)
D64.9
29
Measles suspected
Measles confirmed cases
Rubella confirmed cases
Acute Flaccid Paralysis cases
B05
30
31
32
Under 5 years
M
5 to 19 years
F
M
M
F
A80
Fractures
T14.2
2
Physical traumas, other than fractures
T79
3
Bone and Joint disorder, other than fractures
M25.9
4
Gynecological problems
5
Tuberculosis AFB sputum+
6
Cough Chronic (>15 days)
N94.9
A15.0
B23.8
7
AIDS clinical
B24
8
Skin Infection opportunistic
B23.0
9
Herpes Zoster (Zona / shingles,)
B23.8
10
Candidiasis oral
B20.4
11
Fever Chronic (> 1 month)
12
Diarrhea Chronic opportunistic infections
Needle stick-injuries (or other health worker
W46
K52.9
HIV exposure)
B23.8
14
Goitre
E04.9
15
Vitamin A deficiency – Night blindness
E50.4
16
Leprosy (MB + PB)
A30.9
Under 5 years
M
5 to 19 years
F
M
G) Eye and oral diseases
0-19 y
1
2
3
4
5
6
7
8
9
Glaucoma
Cataract
Refractive error
Diabetic retinopathy
Conjunctivitis
Pinguecula
Uveitis
Eye trauma
Eye problem other
Code
ICD-10
H40
H29.9
H52.7
H36
H10.9
H11.1
H20.9
S05.9
H57.9
10
11
12
Oral diseases
Dental caries
Periodontal disease
Other Teeth and gum infections
K02
K05
K08.9
Version 2.2
F
B06
1
Eye diseases
20 yrs and above
B05
F) New cases of HIV/AIDS/STI/TB and Non-Communicable
diseases
#
Diagnosis
ICD-10
13
03/3/2015
M
F
F
New cases
20-39 y
M
F
20 yrs and above
M
F
40+ y
M
F
Page 2
HMIS
District Hospital Monthly Report
03/3/2015
III. Mental Health
New cases
1
2
3
4
5
6
7
8
9
10
Diagnosis
Post-traumatic stress disorder
Schizophrenia and other psychoses
Neurological problems
Psychosomatic problems
Behavior disorders (not due to alcohol/drugs)
Depression
Suicide (attempted or successful)
Behavior disorders due to use of alcohol/drugs
Other Psychological problems
Epilepsy
0-19
20-39
M F M F
ICD-10
F43.1
F20.9
F29.8
F45.9
F98.9
F32.9
X84
F10-F19
FXX.9
G40.9
Old cases
40 +
M F
0-19
M
F
20-39
M
F
40 +
M
F
IV. Chronic Diseases
New Cases
AGE->
Medical condition
1
2
3
4
5
6
Hypertension
Asthma
Other Chronic obstructive
pulmonary diseases
Diabetes - Type 1
Diabetes - Type 2
Diabetes gestational
ICD-10
0-19
M F
20-39
M F
Deaths
Old Cases
40 +
M F
0-19
M F
20-39
M F
40 +
M F
0-19
M F
20-39
M F
M
40 +
F
I10-I15
J45-J46
J44, J47
E10
E11
O24
V. Other Cardiovascular and Kidney diseases
Medical condition
1
2
3
4
5
6
7
8
9
10
11
Cardiomyopathies
Stroke/TIA
Rheumatic heart disease
Congenital heart disease
Coronary artery disease
Pericardial disease
Heart failure
Other Cardiovascular diseases
Post heart surgery
Renal failure
12
Thyroid Disease
13
Other chronic kidney diseases
Other endocrine and metabolic diseases
Version 2.2
AGE->
ICD-10
0-19
M
New cases
20-39
F
M
F
40 +
M F
0-19
M F
Deaths
20-39
40 +
M F M
F
I42
G45, I60-I64
I05-I09
Q20-Q28
I25.1
I30-I31
I50, I11.0, I97.1, P29.0
I51.6
NA
N17-N19
N00-N08, N10-N16,
N20-N23, N25-N29
E00-E07
E15-E16, E20-E35,
E70-E90
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HMIS
District Hospital Monthly Report
03/3/2015
VI. Injuries
1
2
3
4
5
6
7
8
9
10
Cause of Injury
Road traffic injuries (including cycling)
Self-harm
Interpersonal violence
Other intentional injuries
Falls
Drowning
Fire/burns (thermo, electrical, chemical)
Animal contact
Poisoning
Natural disasters
AGE->
ICD-10
S00-T98
S00-T98
S00-T98
S00-T98
S00-T98
S00-T98
T20-T32
S00-T98
T35-T50
S00-T98
New cases
0-19
20-39
40 +
M F M F M F
Deaths
20-39
40 +
M F
M
F
0-19
M F
VII. Palliative care
Under 20
M
F
20 and older
M
F
Patients receiving palliative care services
Patients with documented pain assessment during the reporting period
Severe pain patients that receive morphine
VIII. Community Checkup
1
2
3
4
5
6
7
Total number of people who consulted for annual medical checkup during the reporting period
Suspected positive at medical checkup who were referred for further diagnosis for the following diseases:
Cardio vascular diseases
Chronic respiratory diseases
Diabetes
Renal Disease
Cancer
Disability
IX. Cancer screening
1
Women screened for cervical cancer
2
Women tested VIA positive during cervical cancer screening
3
Women tested VIA positive and treated with Cryotherapy
4
Women tested VIA positive and referred for treatment
5
Women screened for breast cancer (breast mass)
6
Women referred for breast mass
7
Biopsies collected for all types of cancer
Version 2.2
Page 4
HMIS
District Hospital Monthly Report
03/3/2015
X. Hospitalizations
Internal
Medicine
A) Summary statistics by service
Pediatrics
Surgery
Gyn.
Obst.
Nut. Rehab.
Intensive
care
Neonatology
1 Number of beds (a)
2 Present at the beginning of the month
3 Admissions during the month of which:
3.1 Referred from the Health Centre
3.2 Non-referred patients
4 Discharges during the month (b) of which
4.1 Authorized/Cured
4.2 Abandoned
4.3 Deaths
4.4 Referred
4.5 Counter-referred
5 Present at the end of the month
6 Total hospitalization days for discharged
patients (c)
7 Actual hospitalization days (d)
B) Summary by age
<1 year
M
1
Hospitalized
2
Deaths
1 to 4 years
F
M
5 to 19 years
F
M
20 years and above
F
M
C) Payment for Hospitalization
D) Special causes of admissions and deaths
1
Insured Discharges (Mutuelleetc)
1. Road traffic accidents
2
Non-paying discharges
2. Natural or man-made disasters (epidemic, earthquake, etc)
3
Non-Paying Indigents discharged
3. Workplace injuries
E) Causes of Hospitalization and death at
discharge
M
1
Malaria simple confirmed
B50-B53
2
Malaria severe confirmed
B50-B53
3
Malaria presumptive
B54
4
Borreliosis
A69.2
5
Pneumonia
J12.9 +
J15.9
6
Pleurisy (non-Tuberculosis)
R09.1
7
Respiratory Infection Acute (ARI) Other
J06.9 +
J22
8
Diarrhea bloody (Dysentery)
A09.0
9
Diarrhea with dehydration
A09.9
10
Diarrhea NO dehydration
A09.9
11
Cholera
A00.9
Version 2.2
Admissions
Hospitalization
Under 5
years
F
5 to 19
years
M
F
F
Deaths
Deaths
20 years
and above
Under 5
years
M
M
F
F
5 to 19 years
M
F
20 years and
above
M
F
Page 5
HMIS
District Hospital Monthly Report
E) Causes of Hospitalization and death at
discharge
Hospitalization
Under 5
years
M
12
Typhoid fever (salmonellosis)
A01.0
13
Meningitis
G03.9
14
Measles
B05.9
15
TB pulmonary Sputum positive
A15.0
16
TB extra pulmonary
A31.8
17
Fever Chronic (> 1 month)
B23.8
18
Encephalitis
B22.0
19
Meningitis Cryptococal
G02.1+
B45.1
20
Skin infections
L98.9
21
Diarrhea Chronic opportunistic infection
K52.9
22
HIV Opportunistic Infections Other
B24
23
Trauma Head
S09.9
24
Ruptured spleen
S36.0
25
Fractures, open
T14.2.1
26
Fractures, internal
T14.2.0
27
Trauma Other
T79.9
28
Burns
T29.0
29
Hepatitis
B19.9
30
Cirrhosis of the liver
K74.6
31
Digestive tract Hemorrhages
K92.2
32
Gastritis
K29.0
33
Ulcer, gastro-duodenal
K27
34
Appendicitis
K35.8
35
Hernia
K46.9
36
Peritonitis (non-Tuberculosis)
K65.9
37
Intestinal occlusion
K56.6
38
Urinary tract infections
N39.0
39
Bone infections (including
osteomyelitis)
M86.9
40
Bone and joint disease other
M80-M94
41
Acute Flaccid Paralysis (polio)
A80.3
42
Gynecological problems
N94.9
43
Mastoditis
H70
Version 2.2
03/3/2015
F
5 to 19
years
M
F
Deaths
20 years
and above
Under 5
years
M
M
F
F
5 to 19 years
M
F
20 years and
above
M
F
Page 6
HMIS
District Hospital Monthly Report
03/3/2015
XI. Surgery
1
Services
Type of surgical intervention
General surgery
1. Appendicectomy
Urgent interventions
Planned interventions
Post-surgical Infection Total
2. Hernioraphy
3. Laparotomy
4. Thyroidectomy
5. Adenomectomy
6. General surgery other
2
Gyneco Obstetrical
1. Cesarean
2. Hysterectomy
3. Laparotomy (EUP)
4. Other Laparotomies
5. Myomectomy
6. Fistula Repair
7. Curettage
8. Gyneco-obstetrical surgery other
3
Orthopedic
1. Amputations
2. Osteosynthesis
3 Fracture without implant
4. Orthopedic surgery other
4
Ophthalmologic
1. Glaucoma
2. Trachoma
3. Cataract
4. Trauma
5. Ophthalmological surgery other
5
Plastic surgery
1. Cleft palette, cleft lip
2. Other plastic surgery
6
SURGICAL INTERVENTIONS TOTAL
Of which 1. Major surgery
2. Minor surgery
IV. Physiotherapy
XIII.
XII. Anesthesia
Number
Outpatients
1 General Anesthesia
1 Physical therapy
2 Regional Anesthesia
2 Audiology
3
3 Speech therapy
Local Anesthesia
Hospitalized
4 Other types of anesthesia
I. Gender Based Violence
Under 5 years
M
1
GBV victimswith symptoms of sexual violence (new cases).
2
GBV victimswith symptoms of physical violence (new cases).
3
GBV victims referred for care to higher level health facility
4
GBV victims referred to this facility by police
5
GBV victims referred to this facility by community health workers
Version 2.2
F
5-9 years
M
F
10-18 years
M
F
19 -24 years
M
F
25years and above
M
F
Page 7
HMIS
District Hospital Monthly Report
03/3/2015
I. Gender Based Violence
Under 5 years
M
6
GBV victims HIV+ sero-conversion 3 months after exposure
7
GBV victims with irreversible disabilities due to GBV
8
GBV victim deaths
9
GBV victims pregnant 4 weeks after exposure
10
GBV victimsreceived emergency contraception within 72 hours
11
GBV victims received post exposure HIV prophylaxis within 48 hours
5-9 years
F
M
F
10-18 years
M
19 -24 years
F
M
F
25years and above
M
F
II. Obstetrical Complications
A
Cases and Deaths
OPD NC
ICD-10
O04.9
2
Abortions (symptoms suggesting induced
abortion)
Miscarriages (spontaneous abortions)
3
Ectopic pregnancy
O00.9
4
Threat of premature delivery
O47.9
5
Antepartum Hemorrhage (APH)
O46.9
6
Post-partum hemorrhage (PPH)
O72.1
7
Sepsis / Postpartum infection
O85
8
Prolonged or Obstructed labor
9
Eclampsia /Severe Pre-Eclampsia
O66.9
O15.9
O14.1
1
Under 20 y.
20 y. and over
20 y.and over
Deaths
Under 20 y.
20 y. and over
O03
10
Uterine rupture/tear
S37.6
11
Perineal tear (3rd Degree)
12
Fistula (vesico vaginal or rectal)
O70.2
N82.0
K60.4
13
Anemia Severe (<7gm/dl)
O99.0
14
O98.6
16
Malaria simple in pregnancy
Malaria with minor digestive symptoms in
pregnancy
Malaria severe in pregnancy
17
HIV/Opportunistic Infections
O98.7
18
Obstetrical Complication Other
O75.4
B
Emergency Obstetric Care Interventions (Basic and Comprehensive):
1
Intravenus Antibiotics
2
Intravenus Anti-hypertensives
15
Hospitalized
Under 20 y.
O98.6.1
O98.6.2
3
IntravenusOxytocics
4
Manual removal of placenta
5
Manual vacuum aspiration (Post-Abortion Care)
6
Vacuum extraction
7
(Pre) eclamplsia cases receiving magnesium sulfate
8
Caesarean Section
9
C
Blood transfusion during delivery
D
Women referred for emergency care to higher levels
Number
Women placed under observation for 72 hours or more
Version 2.2
Page 8
HMIS
District Hospital Monthly Report
03/3/2015
III. Deliveries and Births at Health facility
1
Deliveries, total
2
Deliveries, normal
3
Deliveries, abnormal (dystocic)
4
Birth trauma to infant
5
Cleft palette or cleft lip
6
Deliveries 16 – 19 years
7
Deliveries 15 years and under
8
Multiple Pregnancies (twins, triplets)
9
Deliveries referred to higher level referral hospital
10
Maternal deaths during delivery (= subset of all deaths in table VIII.A above)
11
Births, live
12
Birth weight <2.5 kg (alive, not premature)
13
Premature birth weight <2.5 kg (alive, 22-37 weeks)
14
Still births macerated (>22 weeks or >500 grams)
15
Still births fresh (>22 weeks or >500 grams)
16
Deaths at birth of live born babies (born at this health facility) within 30 minutes
17
Newborns breastfed within 1 hour of delivery
18
Newborns who didn’t cry at birth and were resuscitated
19
Newborns resuscitated successfully (cry within 5 minutes)
20
Newborns checked for danger signs in postpartum ward within 24 hours (if mother admitted)
21
Newborns checked for danger signs in postpartum ward before discharge (if mother admitted)
22
Newborns referred to higher level
IV. Kangaroo Mother Care
1
2
3
Low birth weight babies admitted in KMC
KMC Deaths among KMC admissions
KMC Standard follow up visit after discharge within 2 weeks
V. Neonatal causes ofhospitalization and deaths
Disease
Admitted for Hospitalization
0-7 days
8- 28 days
ICD-10
M
1
Asphyxia
P21.9
2
Hypothermia
P80.9
3
Prematurity (22 to 37 weeks)
P07.3
4
Congenital malformations, other
Q89.9
5
Respiratory infections
P28.8
6
Meningitis
P36.9
7
Skin infections
P39.4
8
Urinary tract infections
P39.3
9
TetanusNeonatal
A33
10
Neonatal infections Other
P39.9
11
12
13
F
M
F
Deaths
0-7 days (excluding
8- 28 days
deaths at birth)
M
F
M
F
All other causes of neonatal
morbidity
Total neonates born in this
facility and admitted/died
Total neonates born outside this
health facility and admitted/died
Version 2.2
Page 9
HMIS
District Hospital Monthly Report
03/3/2015
VI. Nutrition Screening (All services)
7 days8 weeks
0-6 days
1
2
2 - 59
months
5-14
years
15 + years
Screened for malnutrition
Malnourished (total):
 2.1 Malnutrition acute severe
 2.2 Malnutrition acute moderate
2.3. Underweight severe
2.4. Underweight moderate
2.5. Malnutrition chronic severe (stunting)
2.6. Malnutrition chronic moderate (stunting)
3
Referred to outpatient malnutrition program
4
Referred to inpatient malnutrition program (District Hospital)
VII. Inpatient Rehabilitation of Malnourished
Pregnant
Women
Acutely Malnourished
Moderate
< 5 years
Lactating
Women
Severe
5 years +
< 5 years
5 years +
1. Present beginning of month
New Cases
2. Hospitalized
Relapsed Cases
Cured
Referred
3. Discharges
Abandoned
Died
4. Present at end of month
VIII. Family Planning
Methods
New
Acceptors
Stopped FP
Active users at
end of month
Quantity
distributed
Stock at end
of month
Days of stockout
1 Oral Contraceptives, projestative
2 Oral Contraceptives, combined
3 Injectables (Depo-Provera)
4 Injectables (Norristerat)
5 Implants
6 IUD
7 Male condoms
8 Female condoms
9 Other barrier methods (gel, diaphram)
10 Cycle beads
11 Auto-observation
12 Tubal ligations
13 Vasectomy
Tests taken
Positive
Negative (no spermatozoids)
14 Sperm control of vasectomy clients
Version 2.2
Page 10
HMIS
District Hospital Monthly Report
03/3/2015
IX. Laboratory
Results
Exams
Positives
Total
Negatives
1. Blood Smears
1.1. Plasmodium
1.2. Micro-filaria
1.3. Borellia
1.4. Trypanosoma
2. Rapid Diagnostic Tests for Malaria
3. Stools…..Samples TOTAL
Of
which
3.1. Entamoebahistolytica
3.2. Entamoeba coli
3.3. Giardia
3.4. Ascariasis
3.5. Ankylostomiasis (hookworms)
3.6. Schistosoma
3.7. Trichuris
3.8. Taenia
3.9. Other parasites in stools
4. Urine
Of
which
4.1. Sugar
4.2. Albumin
4.3. Pregnancy test
5. Sputum (Number of Patients)
Of
which
5.1. Diagnosis of TB by microscopy
5.2. Control of TB positive patients
6. Bacteriology
6.1.Vaginal
swab
Fresh
Gram
Of which diplococcus gram (-)
6.2. Urethral
swab
Fresh
Gram
Of which diploccocus gram (-)
7. Blood
7.1. Hemoglobin
7.2. RPR
7.3. HIV final result
7.4. ESR/VS
7.5. Full Blood Count (FBC/NFS)
Version 2.2
Page 11
HMIS
District Hospital Monthly Report
03/3/2015
IX. Laboratory
Results
Exams
Positives
Total
Negatives
7.6. ALAT(GPT)
7.7. Creatinine
7.8. Blood glucose
7.9. Amylase
7.10. CD4
7.11. Widal
7.12. Pregnancy test
8. Other liquids
8.1. CerebroSpinal fluid
9. Other Lab tests
TOTAL tests conducted in the laboratory
X. Blood Bank Security
Internal
Medicine
A. Transfusions
Pediatrics
Surgery
Gyn. Obst.
Intensive care
Neonatology
1. Number of patients transfused
2. Number of packs of blood
B. Blood pack stock
management
Number received (donated
and from other blood banks)
Number Used
Number Destroyed or
damaged
Remaining in Stock
1. Type A
2. Type B
3. Type AB
4. Type O
I. Medical Imagery
X-ray (Radiology)
Number
Other
1. X-Ray Lung
6. Gastroscopy
2. X-Ray Bones
7. Ultrasound (Echography)
3. X-Ray Abdomen without preparation
8. ECG
4. X-Ray Abdomen with dye
9 Other medical imagery
Number
5. X-ray other
Version 2.2
Page 12
HMIS
District Hospital Monthly Report
03/3/2015
II. Stock Of Tracer Drugs
Tracer drug
1
Amoxycillin syrup 125mg/5ml
2
Ampicillin vial 500mg
3
4
Doxycyclin tab 100mg
Cloxacillin tab 250mg
5
6
7
Mebendazole syrup 100mg/5ml
Gentamycin vial 40mg/ml
Metronidazole vial 500mg/ml
8
9
10
11
12
13
Metronidazole syrup 125mg/5ml
Paracetamol tab 500mg
Ketamine vial 50mg/ml
Ocytocin vial 5ui
Lidocaine vial 2%
Propanolol tab 40mg
14
15
16
Tetracycline ointment
Diazepan tab 5mg
17
Phenobarbital tab 30mg
18
Valproic acid tab 300mg
19
Salbutamol tab 4mg
20
21
Iron sulfate+Folic Acid tab 200mh/0.25mg
Oral Rehydration Salts packet
22
Quinine vial 300mg/ml
23
Quinine tab 300 mg
24
CoartemArtéméther+ Lumefanthrine tab 20 mg + 120mg (6x1)
25
CoartemArtéméther+ Lumefanthrine tab 20 mg + 120mg (6x2)
26
CoartemArtéméther+ Lumefanthrine tab 20 mg + 120mg (6x3)
27
CoartemArtéméther+ Lumefanthrine tab 20 mg + 120mg (6x4)
28
Artemetervial 20 mg/ml
29
Artesunatevial 60mg/ml
30
Ciprofloxacine tab 250mg
31
Cotrimoxazol tab 400 mg + 80 mg
32
Milk therapeutic F100, bag 456 mg
33
Milk therapeutic F75, b ag 410 mg
34
Plumpy nut, bag 920 mg
35
Corn Soya Mix (CSM), kilo
36
Morphine 10 inj mg/ml
37
Morphine 30 tab mg
38
Morphine hcl tab 10mg
39
Captopril tab 25 mg
40
Atenolol tab 25mg
41
Hydrochlorothiazide Solid oral 25 mg.
42
Nifedipine tab (Immediate‐release) 10 mg
43
Methyldopa1 tab 250 mg.
44
Warfarin tab 1mg
45
InsulinInj Rapid 100 UI/ml
46
InsulinInj lente 100 UI/ml
Quantity
Dispensed
Quantity
Expired/Damaged/Lost
Stock at End
of Month
Days of
Stockout
Diazepan vial 5mg/ml
Version 2.2
Page 13
HMIS
District Hospital Monthly Report
03/3/2015
III. Finances
A) Receipts (from all sources including Insurance)
Description
B) Expenditures
Total Amount
Description
Total amount
1. Preventive care
1. Purchase of medicines, medical materials
2. Curative care (including hospitalization)
2. Salaries, social security, professional taxes, personnel payments
3. Deliveries
3. Employee bonuses
4. Laboratory
4. Travel expenses
5. Sale of medicines/ supplies
5. Office supplies / printed materials / medical records
6. Minor surgery
6. Maintenance and repair of medical equipment
7. Issue of Medical-Legal Documents
7. Maintenance and repair of non-medical equipment
8. Sale of patient records/forms
8. Maintenance and repair of transport
9. Transport of patients
9. Maintenance and repair of infrastructure
10. Performance Based Financing
10. Maintenance/cleaning supplies
11. Other State Subsidies
11. Fuel and motor oil
12. Contributions from other donors
12. Water and Electricity
13. Bank interest
13. Communication (Telephone, Internet…)
14. Other receipts
14. Training
Total Receipts (A)
15. Costs associated with indigents
16. Purchase medical equipment
17. Purchase non-medical equipment
18. Purchase transport
19. Other expenses
Total Expenses (B)
Total Amount
C. Mutuelle receipts
D. Other health insurance receipts (RAMA / MMI /
FARG/ Private insurers)
14.1 Co-payments
15.1 Co-payments
14.2 Payment for care
15.2 Payment for care
14.3 Payment for medication
16.3 Payment for medication
E) Credits
Total Amount
F) Debts
Description
Amount
Description
Amount
1. Credits at the beginning of the month (e)
1. Debts at the beginning of the month (i)
2. (+) Additional credits during the month (f)
2. (+) Total debts this month (j)
3. (-) Reimbursements during the month (g)
3. (-) Reimbursements this month (k)
4. Total credits at the end of the month (H) = (e+f)-(g)
4. Debt at the end of the month (L) = (i+ j) -(k)
Total credits: all parties who owe the FOSA money, goods (e.g. medicines) or services (ex. consultations) provided.
Total debts: all parties who whom the FOSA owes money, goods (e.g. medicines) or services (ex. consultations) provided.
G) Financial Statement
Description
Amount
Description
Amount
1. General bank account (m)
6. Total available at the beginning of the month (r)
2. (+) Pharmacy bank account (n)
7. (+) balance of receipts and expenses (s) = (A-B)
3. (+) General cash on hand (o)
4. (+) Pharmacy cash on hand (p)
5. Total available at the end of month (Q) = m+n+o+p
H) Receipts in hand
I) Pending Receipts
1. From the population (C)
2. Indigents (u)
3. Other nonpaying clients* (v)
Q=T
8. Total available at the end of the month (T) = r + s
4. Credits for goods and services
during the month** (w)
* Other non-paying clients: patients other than indigents for whom was not paid for by the patient nor any other
organization.
** All credits in goods (e.g. medicines) or services (ex. consultations) – financial credits are not counted.
Version 2.2
5. Total receipts not
received (X) = u+v+w
J) Total pending
receipts
(Y)= (C) + (X)
I) Ratio of pending
receipts/receipts in
hand (Z) =(X) X100/ (Y)
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