Routine Monthly Report Template printable pdf download

Routine Monthly Report Health Facility:

Payam _________County __________

Report Month/Year:

By _________________________________________

PART 1 / DATA ELEMENT

NUMBER

COMMENTS

1. Curative consultation under 5 male

2. Curative consultation under 5 female

3. Curative consultation 5 years and older male

4. Curative consultation 5 years and older female

5. Antenatal client 1

visit

6. Antenatal client 4

or more visit

7. Antenatal client IPT 2

dose

8. Family Planning new user

9. Delivery in facility by Skilled Birth Attendant

10. Delivery in facility by TBA, MCHW, CHW, Community or Village Midwife

11. Delivery in the community

12. Delivery referred

13. Live birth in facility

14. Post natal client 1

visit

15. Malaria uncomplicated clinically diagnosed under 5 years

16. Malaria uncomplicated confirmed under 5 years

17. Malaria severe under 5 years

18. Malaria uncomplicated 5 years and older

19. Malaria severe 5 years and older

20. Pneumonia presumed under 5 years

21. Diarrhea treated with ORS under 5 years

22. Diarrhea all under 5 years

23. Vitamin A supplement 6-59 months (dose)

24. Vitamin A supplementation new mother

25. Insecticide treated net to under 5 years

26. Insecticide treated net to antenatal client

27. MUAC <115 mm under 5 years

28. MUAC <125 mm under 5 years

29. Death in facility all

30. Death in facility under 5 years

31. Death in facility maternal

32. TB Patient suspected

33. TB patient referred to the TB Management Unit

34. Payam outbreaks detected by the Health Facility

35. Payam outbreaks investigated by the Health Facility 48h after detection

36. Condoms distributed by the facility

37. VCT client seen

38. VCT client tested for HIV – new

39. VCT client tested HIV positive – new

40. VCT client who collects test result

41. Antenatal client tested for HIV

42. Antenatal client who collects test result

43. Antenatal client tested HIV positive – new

44. Antenatal client HIV positive given PMTCT –.new

45. HIV positive patient eligible for ART registered.- new

46. HIV positive patient who receives ART – new

47. Caesarian section done

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Routine Monthly Report Template

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