9-1/0021(W)		REPUBLIC OF NAMIBIA MINISTRY OF HEALTH AND SOCIAL SERVICES                   WARD
(Rev. 08/00)		Health Information System 2000 (HIS2K)                                        RECORD  COPY
	DAILY WARD CENSUS/DISCHARGE REPORT FORM FOR MATERNITY WARDS           (White)
Fold Back Cover Flap Between Next Pink and White Copies. PRESS DOWN HARD. You are making 2 copies!
Date: _____/_____/_____			Facility Name: _______________________________________
dd      mm        yy
Ward Name: _______________________
Form Completed By  ______________________					_________________________________
		Name						Signature
ADMISSIONS - EXPECTANT MOTHERS or POSTNATAL WOMEN (and Babies)
Reg. No.                   Name                                                 Reg. No.                                 Name
01				09
02				10
03				11
04				12
05				13
06				14
07				15
08				16
ADMISSIONS - SICK BABIES
1				5
2				6
3				7
4				8
DISCHARGES, DEATHS, REFERRALS
						TICK ALL
			AGE	SEX		THAT APPLY			DIAGNOSIS OR CAUSE
			Mother=	(Tick		D	R	P	OF DEATH CODE		DATE
Regist.	REGIST.	NAME	Years	ONE)		E	E	R	(Up To TWO Possible;		OF
No.	NO.		Child=			A	F	I	Enter In Order Of		ADMISSION
			Days (D)	M	F	D	R	V	Importance)		(dd/mm/yy)
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
MIDNIGHT CENSUS
Total Number Of WOMEN (Mothers): ___________            Total Number Of SICK BABIES: ____________
			Total Number Of LODGERS: ____________