AMPATH FORM DEVELOPMENT
REQUEST
Date of
request:___20___/_nov_/ 2011
Designation Assistant Professor, Purdue
Mental Health Consultant
Department Head Mental Health
Name Sonak Pastakia
Lukoye Atwoli
Benson Ndegwa Gakinya
E-mail address: spastaki@gmail.com
Program name: Mental Health
Mobile/phone number: 0729027569
Date data collection form approved
_02_/Nov__/2011___
What is the intended name of the data collection tool(Form)
1. AMPATH Psychiatry Initial Visit Form
2. AMPATH Psychiatry Return Visit Form (all questions are included within the return visit form)
3. Psychiatry Mental Health Validated Scales Form (all questions are included within the initial visit form)
4. AMPATH Psychiatry Prescription Form (will likely be programmed separately as part of the pharmacy database
but the concepts should match) All concepts are included within initial visit form)
Source of funding AMPATH/PHC/CDM__________________________________________
Data entry logistics:
Who will pay for the data entry? AMPATH/PHC/CDM______________________________________________________
1.Purpose of the form (This section requires you to attaché a document that quantifies sections: 1(a),(b),(c)
and(d))
1a. What is the Purpose of the data collection tool/form?
The data form will assist in generating reports to enhance the documentation of mental health services for the suppliers of
Zyprexa and Prozac in addition to improving our reporting for the quarterly mental health reports requested by USAID.
1b. What is the targeted population?
Patients receiving mental health services within the AMPATH program at the PHC innovation sites and the main center
here in Eldoret. If possible, it is hoped that these forms could also eventually be used within MTRH to enable us to
document the utilization of zyprexa and Prozac through the prescription forms.
1c. What are the entry and exit criteria’s for all patients enrolling into your program through using the above data
collection tool/form?
We hope to apply the same rules that AMPATH uses for determining which patients are lost to followup since this form
will focus on capturing data for patients receiving mental health services at AMPATH. Entry criteria will be defined as
patients who attend mental health clinic. We would also be interested in assessing which patients are referred for mental
health services from the AMPATH clinic and which patients actually show up for their clinic visits.
1d. What is the frequency of filling out this data collection tool/form?
These tools will be utilized everytime a patient is seen in the mental health clinic here at AMPATH or at the sites. The
comprehensive mental health initial form will be filled on the first visit of the patient.
2. Minimum datasets
(Please include all variables/concepts/Questions) for end products i.e sample reports or program indicators.
This section is likely to take several e-mails before mutual agreements so be as discreet as possible.(Attach
sample reports )
3. Description of variables/concepts and forward to the concepts review team (please group related
variables/concepts/Questions together and apply a logical flow to the questions. Below is the desired template
format to be attached along with this document )
Question No.
variables/concepts/Questions
Proposed answers
Description of
variables/concepts/Question
Ampath form development request version 0.03 May 25th, 2010.
Description of
Proposed
answers
1
See attached spreadsheet
4. Concept review team
Date of request receipt ______/______/_____
Date keys provided to programming
team______/______/______
Concept review team member assigned ___________________
Date assigned ______/______/______
Date programming completed ____/_____/______Sign_________
Date of form implemented _____/______/_____ Sign_________
**Please make sure that the above form is filled after an official approval has been granted by the Program Manager.
In case of any hitches please refer to the form review SOP otherwise contact the form review team. **
Activity
Indicators
Provide access to mental
health care through clinical
visits with trained mental
health staff
Number of service outlets providing mental health services
Number of patients assessed by mental health clinic
Number of days the mental clinic was open with clinicians
available to see clients
Number of newly enrolled clients with mental health disorders
Number of revisits to mental health clients
Total number of mental health clients seen in the month
Total number of mental health clients seen in the month broken
down by mental health diagnosis
Number of mental health clients who are HIV infected
Enhance access to
appropriate mental health
medications
Number of service outlets providing mental health medications
Number of clients receiving Zyprexa (olanzapine)
Number of clients receiving Zyprexa (olanzapine) for approved
indications
Number of clients receiving Prozac (fluoxetine)
Number of clients receiving Prozac (fluoxetine) for approved
indications
Number of mental health clinic days (inclusive of all sites)
where patients were able to access Zyprexa (olanzapine)
Number of mental health clinic days (inclusive of all sites)
where patients were able to access Prozac (fluoxetine)
Number of days where stockouts of Zyprexa (olanzapine)
occurred despite availability in the MTRH store room
Number of days where stockouts of Zyprexa (olanzapine)
occurred due to lack of stocks in the MTRH storeroom
Number of days where stockouts of Prozac (fluoxetine) occurred
despite availability in the MTRH store room
Number of days where stockouts of Prozac (fluoxetine) occurred
due to lack of stocks in the MTRH storeroom
How many patients have had parameters of metabolic
monitoring for zyprexa (olanzapine) addressed at the appropriate
Ampath form development request version 0.03 May 25th, 2010.
Result to be
generated
by AMRS
2
intervals. See table below for monitoring schedule for zyprexa
Train personnel to provide
Conduct health education
Provide continuous
education to staff members
Of the patients tested for metabolic side effects of zyprexa, how
many have abnormal values
Number of trainings conducted
Number of persons trained to provide mental health services
Number of psychotherapy session conducted at the AMPATH
clinics
Number of patients attended psychotherapy sessions at the
clinics
Number of clients visited for home therapy
Number of eligible adults and children provided with a
minimum of one care service (Aggregated by: Age<18, 18+, sex:
male and female)
Number of staff attending continuous professional development
(sensitizations, on job trainings, continuous professional
development, distance learning)
Baseline 1 Month 2 Months
Weight
X
X
3 Months
X
Every 5
Quarterly Annually Years
X
Waist
Circumference X
X
Blood Pressure X
X
X
Fasting
Glucose
X
X
X
Fasting Lipid
X
Profile
X
Ampath form development request version 0.03 May 25th, 2010.
X
3