Private Dispensary 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 sent
7. Signature
4. Signature
8. Date entered in RHMIS
II. Outpatient Consultations
A) Outpatient Morbidity summary table
<5 yr
M
F
>=5 – 19 yr
M
Total
B) Health insurance status of new cases
F
>=20 yr
M
1. Insured (Mutuelle or other insurance members)
F
1. New cases
2. Non-Paying New cases
2. Old cases
3. Number of Indigents of non-paying new cases
C) Referrals
Total
Total
D) Special causes of OPD visits
1.Referred to Hospital
1. Road traffic accidents
2. Counter referrals received
2. Natural or man-made disasters (floods, earthquakes, etc)
3. Workplace accidents
E) New cases of priority health problems in OPD
#
Diagnosis
ICD-10
1 Fever >=37 C (all causes)
2 Diarrhea with dehydration
A09.1
A09.2
3 Diarrhea no dehydration
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Diarrhea bloody (dysentery)
Food poisoning
Ear Infections
Schistosomiasis
Ascaris lumbricoides
Trichuris trichiura
Hookworm
Entamoeba
Giardia
Taenia
Malaria confirmed simple (not pregnant)
Malaria confirmed simple in pregnancy
Malaria confirmed with minor digestive
symptoms (not pregnant)
Malaria confirmed with minor digestive
symptoms in pregnancy
Malaria (presumptive not pregnant)
Herpes simplex infections
Meningitis suspected
Eye problem Trachoma
A09.3
A05
H65
B65
B77
B79
B76
A06
A07
B68
B53.8
B53.8.0
B54
B00.9
G03.9
A71.9
<5 years
M
5-19 years
F
M
F
20 years and above
M
F
Private Dispensary HMIS Monthly Report
28/1/2014
E) New cases of priority health problems in OPD
#
Diagnosis
22 Eye problem Trichiasis
23 Eye problem Other
24 Pneumonia
25 Respiratory infections acute (ARI) other
26 Teeth and gum Infections
27 Gastritis and duodenitis
28 Abscesses
29 Ulcers of skin
30 Skin Infection Scabies
31 Skin Infection Fungal (mycoses) superficial
32 Skin Infection Other
33 Urinary Tract Infections
34 Anemia (confirmed)
35 Acute flaccid paralysis (suspected polio)
<5 years
ICD-10
H02.0
H57.9
J18.9
J22, J06.9
K08.9
K29.9
L02.9
L89
B86
B36.9
L00-L08
N39.0
M
5-19 years
F
M
F
20 years and above
M
F
D64.9
A80
F) New cases of HIV/AIDS/STI/TB and Non-Communicable
diseases
#
Diagnosis
ICD-10
1 Fractures
T14.2
2 Physical traumas, other than fractures
T79
3 Discharge, Urethral Male
R36
4 Discharge, Vaginal
N89.8
5 Genital ulcers
N48.5
6 Bubo / scrotal swelling
K40.9
7 Gynecological problems
N94.9
8 Tuberculosis AFB sputum+
A15.0
9 Cough Chronic (>15 days)
B23.8
10 AIDS clinical
B24
11 Skin infections opportunistic
B23.0
12 Herpes Zoster (Zona / shingles,)
B23.8
13 Candidiasis oral
B20.4
14 Fever Chronic (> 1 month)
B23.8
15 Diarrhea Chronic opportunistic infection
K52.9
Needle stick-injuries (or other health worker
16 HIV exposure)
W46
17 Goitre
E04.9
18 Vitamin A deficiency – Night blindness
E50.4
19 Heart disease acute
5 to 19 years
<5 years
M
F
M
F
20 yrs and above
M
F
III. Chronic Diseases and Mental Health
Diagnosis
ICD-10
1 Psychological/Mental problems
2 Epilepsy
3 Suicide (attempted or successful)
3 Diabetes, Insulin dependent
4 Diabetes, non-insulin dependent
5 Diabetes, gestational
6 Hypertension
7 Stroke
8 Rheumatic heart disease
9 Congestive heart failure
10 Leprosy (MB + PB)
Version 1.7
New Cases
Under 20 y
20 y and above
M
F
M
F
Old cases
Under 20 y
20 y and above
M
F
M
F
FXX.9
G40.9
X84
E10
E11
Q24
I10
I64
I09
I60
A30.9
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Private Dispensary HMIS Monthly Report
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12
13
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28/1/2014
Cardio vascular disease other
Asthma
Chronic obstructive lung diseases
Bronchiectasis (chronic bronchitis)
I51.6
J45.9
J44
J47
IV. Vaccinations
Vaccine Antigen/Item distributed
1
BCG
2
Polio-Zero (P0)
3
Polio-1 (OPV1)
4
Polio-2 (OPV2)
5
Polio-3 (OPV3)
6
DTP-HepB-Hib1
7
DTP-HepB-Hib2
8
DTP-HepB-Hib3
9
Pneumococus 1
10
Pneumococus 2
11
Pneumococus 3
12
Rotavirus 1
13
Rotavirus 2
14
Rotavirus 3
15
Measles & Rubella (MR)
16
Insecticide impregnated bed nets distributed
Vaccines for other age groups:
17
0 -11 Months
1 Year
15 Months
16 Months +
Measles vaccination
12 years
18
HPV 1
19
HPV 2
20
HPV 3
V. 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, progestative
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
Version 1.7
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Private Dispensary HMIS Monthly Report
28/1/2014
VI. Male Circumcision
< 30 days
30 days - 14 years
>=15 years
1. Male circumcisions performed in the facility
VII. Laboratory
Results
Exams
Positives
Negatives
Total
1. Blood Smears
1.1. Plasmodium
1.2. Micro-filaria
1.3. Borellia
1.4. Trypanosoma
2. Rapid Diagnostic Tests for Malaria
3. Stools (number of samples analyzed)
Of which
3.1. Entamoeba histolytica
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
4. Urine
Of which
4.1. Sugar
4.2 Albumin
4.3 Pregnancy test
5. Sputum
Of which
5.1. Diagnosis of TB by microscopy
5..2 Control of TB positive patients
6. Blood
Of which
6.1. RPR
6.2. HIV final result
6.3. Hemoglobin
6.4. ESR/VS
6.5. Full Blood Count (FBC/NFS)
6.6. ALAT (GPT)
6.7. Creatinine
6.8. Blood glucose (glycemie)
6.9. Amylase
6.10. CD4
7. Lab tests, other
Version 1.7
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