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
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
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
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?
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