9-1/0029

REPUBLIC OF NAMIBIA MINISTRY OF HEALTH AND SOCIAL SERVICES

(Rev. 08/00)

Health Information System 2000 (HIS2K)

OUTPATIENT DEPARTMENT MONTHLY SUMMARY REPORT FORM

FACILITY NAME: ______________________     REPORT FOR: MONTH: ______________ YEAR: _______

IF THIS FORM IS FOR OUTREACH SERVICES ONLY, TICK (3) HERE: ___

UNDER-5

5-17 YEARS

18 AND OVER

FIRST VISIT  ……………….……………………………..

_____________

_____________

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CLASSIFICATION/DIAGNOSIS

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

1

** Acute Flaccid Paralysis……….……...…………...……………….

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_____________

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1

2

Anaemia………….………………………………………….…………………………………

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_____________

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2

Cardio-Vascular System

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

3

Hypertension………………..………………………..………………..…….

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_____________

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3

4

Other Cardio-Vascular/Circ. Sys. Disease……….

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_____________

_____________

4

5

Dental Disorder/Disease…………………….…………………………………………………..

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_____________

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5

Endocrine System

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

6

Diabetes…………………………………………………………………………….

_____________

_____________

_____________

6

7

Other Endocrine System Diseases………………………………………………

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_____________

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7

Ear, Nose and Throat Disorders

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

8

Ear Disease/Disorder…………………………………………………………….

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_____________

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8

9

Nose/Throat Disease/Disorder………………………………………………..

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9

Eye Diseases/Disorders

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

10

Conjunctivitis………………………………………………………………..

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_____________

_____________

10

11

Other Eye Disease/Disorder………………………………..

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_____________

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11

Gastro-Intestinal System

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

12

Diarrhoea WITHOUT Blood………………………………………………………..

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_____________

_____________

12

13

Diarrhoea WITH Blood…………………………………………………………….

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_____________

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13

14

Other Gastro-Intestinal Disease/Disorder.……...…..

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_____________

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14

15

Contraception, Gynae, Pregnancy, Obstetric……………………………………

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15

Infectious Diseases (Clinical Diagnosis)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

16

Malaria………………………………………………………………………………..

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16

17

** Measles…………………………………………..………………………………..

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17

18

** Meningitis………………………………………………………………………….

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18

19

Intestinal Worms (Parasitic Infections)………………………………

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19

20

** Neo Natal Tetanus………………………………………..………………………………..

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x x x x x

x x x x x

20

21

Tuberculosis

_____________

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21

22

Other Infectious Disease……………………………………

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22

23

Malnutrition…………………………………………………………………………………….

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23

24

Musculo-Skeletal System Disorders……………………………………………………………….

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24

25

Neurological System Disease/Disorders………………………………………

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25

26

Paediatric Disease (see Treatment Manual)…………………………………….

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_____________

x x x x x

26

27

Psychiatric Disorders……………………………………………………………………..

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_____________

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27

Respiratory System

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

28

Asthma/Bronchial Spasm…………………………………………………………………………..

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28

29

Common Cold…………………………………………………………………………………

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29

30

Pneumonia……………………………………………………………………………

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30

31

Other Respiratory System Disease……………………………………………………………………

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31

Sexually Transmitted Infections (STI)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

32

HIV Disease (Clinical Diagnosis)…………………………………………………..

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_____________

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32

33

Genital Ulcer Disease………………………………………………………………..

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33

34

Pelvic Inflammatory Disease (PID)…………………………………………………

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34

35

Urethral Discharge………………………………………………………………

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35

36

Vaginal Discharge…………………………………………………………………

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36

37

Other STIs………………...…………………………………………………………………..

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37

38

STI Partner Referral………………...…………..…………………

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38

Skin Disease

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

39

Scabies……………………...……………….………...…………..…………………

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39

40

Other Skin Disease…...……………….………...…………..…………………

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40

41

Trauma/Injuries……………………………………………………………………………………………..

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41

42

Uro-Genital Disorders (NOT STI)…………………………………………………………..

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42

43

Other Syndrome/Diagnosis……………………………………………………………….

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43

44

Motor Vehicle Accident……………………………………………………

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44

45

Occupation - Related Disease/Condition…………………………………

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45

Continued On Back

OTHER VARIABLES

TOTAL FOR

MONTH

1

REVISIT/FOLLOW-UP VISIT………………………….……………………………

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1

2

HIV Disease/AIDS………………….………………………………..……………………………..

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2

3

Diabetes………………..…………………………………………………………………………………….

___________

3

4

Hypertension……………………………………………………………………………………………

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4

5

Psychiatric……………………………………………………………………………………………….

___________

5

6

All Other Diagnoses………………………………………………………………………………….

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6

7

SEEN BY DOCTOR  (At First OR Follow-Up Visit)…………….

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7

ADDITIONAL SERVICES

8

Emergencies………………………………………………………………………………………………..

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8

9

Procedures (Incisions, Stitches, etc.)………………………………………………………………..

___________

9

10

Dressings…………………………..…………………………………………………………………………………..

___________

10

11

Injections (Other Than Immunizations, FP)……………………………………………………………………….

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11

12

Pap Smears…………………………………………………………………………………………………………….

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12

13

Pregnancy Tests………………………………………………………………………………………………….

___________

13

14

Lab Samples Taken (Blood, Stool, etc.)……………………………………………………………………………..

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14

15

Medical/Physical Exam Only (also ECG, etc.)……………………………………………………………….

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15

16

TB DOTS Only……………………………………………………………………………………………………….

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16

17

REFERRALS FROM ANOTHER FACILITY……………………………………………………………

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17

18

REFERRALS TO OTHER FACILITY…………………………………………………………………….

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18

19

ADMISSIONS TO THIS FACILITY…………………………………………………………………………

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19

20

EMERGENCY DELIVERIES (IN OPD/CLINIC)………………………………………………………….

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20

21

DEATH IN OPD (not DOA)………………………………..

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21

FORM COMPLETED BY: NAME: _________________  SIGNATURE: _______________  DATE: ________

FORM CHECKED BY: NAME: _________________  SIGNATURE: _______________  DATE: ________