| 9-1/0026 |
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REPUBLIC OF NAMIBIA MINISTRY OF HEALTH
AND SOCIAL SERVICES |
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PAGE
1 OF 3 |
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| Rev. 08/00 |
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Health Information System 2000
(HIS2K) |
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SUPPORTIVE HEALTH
SERVICES/ACTIVITIES MONTHLY SUMMARY REPORT FORM |
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| Report For
Month Of ________________ Year:
__________ |
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| Facility
Name: ___________________________
Type ( 4 ONE ) : ___Hospital ___H/C ___Clinic |
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| SCHOOL
HEALTH SERVICES |
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4 = No School Health Services Data To Report This Month |
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| Number
of Schools Visited
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SH 1. |
_____ |
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| Number
of GRADE 1 Children Examined
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SH 2. |
_____ |
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| Number
of GRADE 6 Children Examined
.. |
SH 3. |
_____ |
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| Number
of Referrals to Health Facility or Doctor
.. |
SH 4. |
_____ |
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| Number
of Children Immunized
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SH 5. |
_____ |
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| Number
of Children with Disabilities
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SH 6. |
_____ |
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| COMMUNITY-BASED
HEALTH CARE (CBHC) |
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4 = No CBHC Services Data To Report |
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| Affiliated/Registered
CBHC Workers (from CBHC Register) |
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This Month |
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Total No. Affiliated |
No. Added |
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No. of |
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With Facility |
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This Month |
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Meetings |
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| Community
Health Workers (CHW)/Community's |
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| Own Resource Persons (CORP)
.. |
CB 1. ______ |
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CB 2. ______ |
CB 3. ______ |
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| Traditional
Birth Attendants (TBA)
.. |
CB 4. ______ |
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CB 5. ______ |
CB 6. ______ |
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| Traditional
Healers (TH)
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CB 7. ______ |
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CB 8. ______ |
CB 9. ______ |
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| Total
Number of Cases (from Activity Reports) |
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IDENTIFIED |
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REFERRED |
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ARI
. |
CB 10. ______ |
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CB 11. ______ |
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Diarrhoea
..
. |
CB 12. ______ |
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CB 13. ______ |
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Tuberculosis
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CB 14. ______ |
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CB 15. ______ |
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Malnourished
Children
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CB 16. ______ |
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CB 17. ______ |
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Persons With Disability
(Mental or Physical)
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CB 18. ______ |
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CB 19. ______ |
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Measles
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CB 20. ______ |
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CB 21. ______ |
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Malaria
(Probable)
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CB 22. ______ |
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CB 23. ______ |
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STI,
HIV/AIDS
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CB 24. ______ |
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CB 25. ______ |
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Children Needing
Vaccination(s)
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CB 26. ______ |
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CB 27. ______ |
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Total Number |
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| Women
Delivered (at home or outside facility)
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CB 28. ______ |
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| Pregnant
Women Attended
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CB 29. ______ |
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| Home
Visits Done
. |
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CB 30. ______ |
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| Health
Education Sessions Conducted
. |
CB 31. ______ |
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| Number
of Condoms Distributed
.. |
CB 32. ______ |
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| Number
of ORS Sachets Distributed
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CB 33. ______ |
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| Number
of Community Meetings, meetings with Community leaders or Development
Committees
CB 34. _____ |
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Continued
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| HIS2000
Supportive Health Services/Activities Monthly Report Form
PAGE 2 OF 3 |
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| REHABILITATION |
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4 = No Rehabilitation
Data To Report This Month |
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of Data: Rehabilitation Officer's Diary, Registers, Records] |
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| INSTITUTIONAL-BASED
REHABILITATION AND CARE |
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Number Seen This Month |
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New |
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Patients |
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Revisits |
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| Occupational
Therapy
..
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RE 1. |
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RE 2. |
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| Physiotherapy
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RE 3. |
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RE 4. |
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| Medical
Rehabilitation
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RE 5. |
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RE 6. |
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| Speech
Therapy
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RE 7. |
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RE 8. |
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| Number
of Wheel Chairs Distributed
....
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RE 9. |
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| Number
of Other Assistive Devices (not wheelchairs) Distributed
RE 10. |
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| OUTREACH
REHABILITATION SERVICES |
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| Number
Of Outreach Points Visited
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..
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RE 11. |
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| COMMUNITY-BASED
REHABILITATION AND CARE |
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| Number
Of People With Disabilities Identified And |
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| Referred To Health Facilities Or
Specialised Services
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RE 12. |
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| ORTHOPAEDIC
TECHNICAL SERVICES |
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4 = No Orthopaedic
Technical Services Data To Report |
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| [Source
of Data: OTS Registers, Records] |
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This Month |
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| Total
Number of New Patients
..OT 1. |
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| Total
Number of Revisits
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..OT 2. |
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| Total
Number Of Upper Limb Prostheses
OT 3. |
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| Total
Number Of Lower Limb Prostheses
OT 4. |
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| Total
Number Of Upper Limb Orthoses
...OT 5. |
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| Total
Number Of Trunk Orthoses
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.OT 6. |
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| Total
Number Of Other Devices/Aids
...OT 7. |
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Continued
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| HIS2000
Supportive Health Services/Activities Monthly Report Form
PAGE 3 OF 3 |
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| OUTREACH
SERVICES |
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4 = No Outreach Services
Data To Report This Month |
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of Data: Registers maintained during outreach trips; vehicle(s) trip reports
and/or log books] |
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| Total
Number of (Formal/Official) Outreach Sites/Points
..
...
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OR 1. |
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| Number
of Outreach Sites/Points PLANNED/EXPECTED To Be Visited This Month
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OR 2. |
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| Number
of Outreach Sites/Points Visited This Month
..
...... |
OR 3. |
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| Total
Kilometers Driven for Outreach Services This Month
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...
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OR 4. |
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4 = No HIV Counselling Data To Report This Month |
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| [Source
of Data: HIV Counselor(s) Records] |
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MALE |
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FEMALE |
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| Number
of HIV Pretest Patients Counseled
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HI 1. |
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HI 2. |
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| Number
of HIV Post-test Patients Counseled
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HI 3. |
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HI 4. |
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| Number
of HIV Patients Given Follow-up Counseling
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HI 5. |
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HI 6. |
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| Number
of HIV Positive Results
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HI 7. |
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HI 8. |
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| BLINDNESS
PREVENTION PROGRAMME |
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4 = No Blindness Prevention Data |
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Be Completed ONLY At Facilities Having An Eye Care Unit) |
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To Report This Month |
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| [Source:
Blindness Prevention Programme Register] |
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Total Number For Month |
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NEW CASES |
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FOLLOW-UPS |
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SURGERY |
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Cataracts
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BP 1. _____ |
BP 2. _____ |
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BP 3. _____ |
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Glaucoma
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BP 4. _____ |
BP 5. _____ |
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BP 6. _____ |
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Trachoma
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BP 7. _____ |
BP 8. _____ |
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BP 9. _____ |
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Vit. A Deficieny/Xerophthalmia
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BP 10. _____ |
BP 11. _____ |
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Blindness
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BP 12. _____ |
BP 13. _____ |
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| HFR
HEARING SCREENING |
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4 = No HFR Screening Data |
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| (High
Frequency Rattle hearing screening, 9-12 month-old children) |
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To Report This Month |
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| [Source:
Infant Hearing Screening Tally Sheets] |
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PASSED |
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FAILED |
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Initial Screening Results
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HE 1. _____ |
HE 2. _____ |
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Retest Results
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HE 3. _____ |
HE 4. _____ |
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| DIAGNOSTIC
X-RAY [Source of data: Radiology Department Register] |
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4 = No X-Ray Data To |
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Report This Month |
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INPATIENTS |
OUTPATIENTS |
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| Number of
PATIENTS X-Rayed
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XR 1. |
_____ |
XR 2. |
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| Number of
FILMS Processed
..
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XR 3. |
_____ |
XR 4. |
_____ |
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