| 9-1/0022 |
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REPUBLIC OF NAMIBIA MINISTRY OF
HEALTH AND SOCIAL SERVICES |
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| Rev. 08/00 |
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Health Information System 2000
(HIS2K) |
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MATERNITY (INPATIENT) DEPARTMENT
MONTHLY SUMMARY REPORT FORM |
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| Report For
Month Of ________________ Year:
__________ |
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| Facility
Name: ___________________________
Type (4 ONE ) : ___
Hospital ___ Health Centre ___ Clinic |
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| NOTE:
Source Of Data For This Report Is The (New) Delivery Register. The numbers correspond to the numbers
marked with a * |
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the top and bottom of the corresponding column in the register. Refer to HIS 2000 Instructions Manual Maternity Reports chapter |
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detailed instructions. |
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| 1A. ADMISSION/Private/State/PRIVATE Patients
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1A |
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| 1B. ADMISSION/Private/State/STATE Patients
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1B |
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| 2.
ANC VISITS/Total Number/NONE
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2 |
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| 3.
ANC VISITS/Total Number/1 or 2
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3 |
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| 4.
ANC VISITS/Total Number/3 or More
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4 |
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| 5.
ANC VISITS/Trimester of First Visit/1 (0-15 Weeks)
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5 |
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| 6.
ANC VISITS/Trimester of First Visit/2 (16-28 Weeks)
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6 |
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| 7.
ANC VISITS/Trimester of First Visit/3 (29 or More
Weeks)
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7 |
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| 8.
ANC VISITS/TT2 or More
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8 |
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| 9.
PRE-DELIVERY STATUS/Premature Labour
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9 |
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| 10.
DELIVERY TYPE/Normal
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10 |
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| 11A.
DELIVERY TYPE/Assisted/Vacuum Extraction..
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11A |
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| 11B.
DELIVERY TYPE/Assisted/Forceps.
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11B |
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| 12.
DELIVERY TYPE/Assisted/Caesarian Section..
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12 |
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| 13.
BORN BEFORE ARRIVAL
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13 |
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| 14.
COMPLICATIONS/Maternal Death
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14 |
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| 15.
BABY/Still Birth/Fresh
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15 |
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| 16.
BABY/Still Birth/Macerated
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16 |
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| 17.
BABY/Live Birth/Live Birth
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17 |
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| 18.
BABY/Live Birth/Birthweight/Less Than 2500 Grams
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18 |
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| 19.
BABY/Live Birth/Breastfed (Before 1/2 Hour)
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19 |
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| 20.
BABY/Live Birth/Neonatal Death
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_____ |
20 |
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| 21. AT DISCHARGE/Mother/Vitamin
A
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21 |
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| 22. AT DISCHARGE/Baby/BCG
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22 |
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| 23. AT DISCHARGE/Baby/OPV
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23 |
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| 24. AT DISCHARGE/Baby/Breastfeeding
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24 |
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