HMIS 105 Health Unit Outpatient Monthly Report
HMIS 105 Health Unit Outpatient Monthly Report
HMIS 105 Health Unit Outpatient Monthly Report
MINISTRY OF HEALTH
Objective: To report the monthly data for OPD attendances, diagnoses, MCH, HIV/AIDS service,
Laboratory, stock status of essential drugs and supplies and finances, among others.
Copies: This report form is in triplicate. The original (white) copy is sent to the District; the
duplicate (pink) copy is sent to the HSD and the triplicate (yellow) copy is retained by the
Health Facility.
For Regional Referral Hospitals and National Referral Hospitals, the original (white) copy
is sent to the respective district health office/City Authority for KCCA, and the other copies
should be retained by the facility.
PROCEDURE:
1. All health units must compile and submit the HEALTH UNIT OUT-PATIENT MONTHLY
REPORT (HMIS 105). The health unit is required to compile the type of report by origin of the
population its serves e.g Refugee hosting district they will report a report type for Nationals and for
refugees respectively.
Page 1 - 9 contains:
Section 1 with three sub-sections (1.1-OPD ATTENDANCES, 1.2-REFERRALS AND
1.3-OUTPATIENT DIAGNOSES). The values are obtained from tables 1a, 1b, 1c, 1d and 1e (Health
Unit Outpatient daily diagnoses). If the district wishes to include additional diseases of local interest,
they may do so under the variable of other diagnoses. The DHMT will be responsible for ensuring
all the health units in the district are aware of the chosen additional diagnoses.
2 Page 10 - 17 contains:
Section 2, shows a summary of Maternal and Child Health Services, it includes sub-sections
(2.1-Antenatal, 2.2-Maternity, 2.3-Postnatal, 2.4-Exposed Infant Diagnosis services, 2.5-Early
retention monitoring for EMTCT women, 2.6-Family Planning and 2.7-Child Health Services. The
values are obtained from Table 2a (Health Unit Daily Maternal Health Attendance Summary), Table
3a (Health Unit EPI Daily Attendance Summary) and Table 4a (Health Unit Daily Family Planning
Summary).
For BCG, children above one year receive twice as many doses of vaccine as the under one year
olds and therefore total number of doses administered = No of children <1yr immunized + No of
children >1yr immunized x 2.
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HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 3
4. Page 23 contains:
Section 5: Safe Male Circumcision. Information is obtained from the Safe Male Circumcision Register.
5. Page 24 – 25 contains
Includes Section 6: Essential Medicines and Health Supplies Stock Status where values are
obtained from the Health Facility Stock Book and Stock Cards.
Sub-Section 7, 8 and 9: shows a summary of outreach activities, Meeting and Support supervision
activities both planned and actual number carried out, this is obtained from the health facility work
plan and outreach records of the Individual units within the health facility.
Note: The storekeeper should also report verbally to the Health Facility In-charge and District/HSD
Authorities whenever the stock levels reach minimum stock level.
6. Page 26 - 29 contains:
Section 10: Includes a summary of laboratory tests. The information is obtained from Table 17a
(Laboratory Tests Daily Summary) and
Section 11: (Financial summary): The information for the financial summary is obtained from
Health Facility Cash Analysis Book.
Section 12: (comments by the health facility in-charge): A copy of the comments should be
written in the health unit’s LOGBOOK.
Pregnant /
Pregnant /
Pregnant
Lactating
Pregnant
Lactating
Pregnant
Lactating
Non
Non
Non
/Lactating
/Lactating
/Lactating
Pregnant
Pregnant
Pregnant
Pregnant
Pregnant
Pregnant
Non
Non
Non
1.5 Nutrition Services (Continued)
NA03b. MAM using W/H or L
W/H or L: ≥ -3 SD & < -2 SD
NA03c. SAM using MUAC
MUAC: < 11.5cm (children
0-59 mths) MUAC: <19.0cm
(PLW 10-25+ yrs)
NA03d. SAM using W/H or L
W/H or L: < -3 SD
NA03. No. of NA03e. SAM With Oedema
identified NA03f. Moderately
malnourished Malnourished
clients
this month; (5-9yrs & 10-19yrs: <- 2SD & ≥-3SD;
>19yrs: ≥16.0 & ≤16.9)
NA03g. Severely Malnourished
(5-9yr & 10-19 yrs: <
-3SD;>19yrs: < 16.0)
NA03h. Overweight (5-9yrs:
>+1SD & ≤+3SD; >19yrs:
≥25.0 & ≤29.9)
NA03i. Obese (5-9yrs & 10-
19yrs: <+ 2SD; >19yrs: ≥ 30.0)
NA04. No. of SAM NA04a. Total
admissions in
OTC this month; NA04b. New Admissions
NA05. No. of NA05a. Relapses
Readmissions into
OTC this month; NA05b. Defaulters
NA06. No. of MAM NA06a. Total
admissions in
Supplementary
Feeding Care (SFC); NA06b. New Admissions
NA07. No. of NA07a. Relapses
Readmissions in
SFC this Month NA07b. Defaulters
NA08a. Discharged as cured
within this month
NA08. No. of NA08b. Did not respond to care
clients in OTC (non-response) after 3
with SAM months of treatment
admitted into NA08c. Defaulted from care
treatment and within this month (absent for 2
consecutive visits)
NA08d. Died during treatment
within this month
NA09. Total number of days spent in OTC for all
clients discharged as cured this month
NA10a.Discharged as cured within this month
NA10. No.
of clients NA10b. Did not respond to care in
with MAM SFC (non-response) after 3 months of
admitted treatment
into NA10c. Defaulted from care within this month
treatment (absent for 2 consecutive visits)
and
NA10d. Died during treatment within
this month
NA11. Total number of days spent in SFC for all
clients discharged as cured this month
NA12. No. of malnourished clients who are
positive for TB
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HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 10
2.0 MATERNAL AND CHILD HEALTH SERVICES 2.1 ANTENATAL (Continued) NUMBER
2.1 ANTENATAL NUMBER Below 15 years
Below 15 years 15-19 years
15-19 years AN11. IPT 4 & 4+ Dose 20-24 years
AN01.ANC 1st contacts/ Total 20-24 years 25-49 years
visits for women 25-49 years 50+ years
50+ years Screened for TB
AN12. TB Screening for
No. in 1st Trimester ANC clients Presumed to have TB
Below 15 years Diagnosed with TB
15-19 years Total
AN13. Blood & Rhesus group (O)
AN02.ANC 4th contacts/ 20-24 years Rhesus O+
visits for women
25-49 years Total
AN14. Blood & Rhesus group (A)
50+ years Rhesus A+
Total
Below 15 years AN15. Blood & Rhesus group (B)
Rhesus B+
15-19 years
AN03. ANC 4+ contacts/ AN16. Blood & Rhesus group Total
20-24 years
visits for Women (AB) Rhesus AB+
25-49 years
AN17.No. of pregnant women who were tested for
50+ years Anaemia using Hb Test at ANC 1st Contact / visit
Below 15 years AN18. No. of pregnant women with Anaemia
(Hb <10g/dl) at ANC 1st Contact / visit
15-19 years
AN04. ANC 8 contacts/ AN19. No. of pregnant women who were tested for
20-24 years anaemia using Hb test at ANC after 36 weeks
visits for Women
AN20. No. of pregnant women with Anaemia
25-49 years
(Hb <10g/dl) at ANC after 36 weeks
50+ years AN21. Pregnant Women receiving at least 30 tablets of
Below 15 years Folic Acid and Iron Sulphate at ANC 1st contact / visit
(Only Folic Acid recommended during 1st trimester)
15-19 years AN22. Pregnant Women receiving at least 30 tablets
AN05. Total ANC contacts/
visits (new clients + Re- 20-24 years of Folic Acid and Iron Sulphate at ANC after 36
attendances) weeks of gestation
25-49 years
AN23. Pregnant Women receiving LLINs at ANC 1st visit
50+ years
AN24. No. of pregnant women Total U/S Scan done
AN06. Referrals to ANC Total referrals who received obstetric-ultra No. done before 24
unit sound scan during any ANC weeks of gestation
From community services visit in the reporting month and below
Total referrals AN25. No. of pregnant women Total
AN07. ANC Referrals from
unit HIV+ mothers newly dewormed or receiving After 28 weeks of
enrolled in MCH groups mebendazole gestation
Below 15 years AN26. Pregnant Women No. Tested
15-19 years tested for syphilis for the first No. Tested Positive
time in this pregnancy
AN08. First dose IPT No. started on
20-24 years syphilis treatment
(IPT1)
25-49 years No. Tested
50+ years AN27. Male partners tested for No. Tested Positive
syphilis
Below 15 years No. started on
syphilis treatment
15-19 years No. Tested
AN09. Second dose IPT AN28. Pregnant women tested No. Tested Positive
20-24 years
(IPT2) for Hepatitis B.
25-49 years No. started on Hep
B treatment
50+ years Total Number ANC1
Below 15 years AN29. Pregnant Below 15 years Number ANC1
15-19 years women newly 15-19 years Number ANC1
AN10.Third dose IPT tested for HIV in
20-24 years 20-24 years Number ANC1
(IPT3) this pregnancy at
25-49 years any ANC visit (TR 25-49 years Number ANC1
50+ years & TRR) 50+ years Number ANC1
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HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 11
2.1 ANTENATAL (Continued) NUMBER 2.1 ANTENATAL (Continued) NUMBER
Total Total ART-K during the month
Number ANC1
25-49 years
Below 15 years Number ANC1 Viral Load Samples
AN30. Pregnant collected during the month
15-19 years Number ANC1
Women tested HIV+ Viral Load results Returned
for 1st time this preg- 20-24 years Number ANC1 AN34.HIV+ during the month
nancy (TRR) at any pregnant
25-49 years Number ANC1 women already Viral Load Suppressed
ANC Visit during the month
50+ years Number ANC1 on ART before
1st ANC (ART-K) Total ART-K during the month
Below 15 years Number ANC1 (Continued) Viral Load Samples
50+ years
15-19 years Number ANC1 collected during the month
AN31. HIV+ Pregnant Viral Load results
women assessed by 20-24 years Number ANC1 Returned during the month
CD4 Viral Load Suppressed
25-49 years Number ANC1 during the month
50+ years Number ANC1 AN35. Pregnant women Total (TR+ &TRR+)
AN32. HIV+ pregnant who re-tested later in
Below 15 years pregnancy HIV+ (TRR+)
women initiated on
ART for eMTCT at 15-19 years AN36. HIV+ pregnant women given ARV prophylaxis for
the un born infants for the 1st time in ANC
Any visit irrespective 20-24 years
of when tested HIV+ AN37. Pregnant Total
(TRR, TRR+ and 25-49 years women given
HIV+ not yet started self-testing kits for Tests returned HIV+
50+ years their male partners Tests returned HIV negative
ART(TRR√ & TRRK))
Total (TRK + TRRK) AN38: Male partners Total tested (TR & TRR)
received HIV test
AN33. Pregnant Below 15 years results in eMTCT HIV+ (TRR).
HIV+ (TRRK)
< 2.5 Kg
during the month
Viral Load results MA04c. Fresh still Total
Returned during birth
the month < 2.5 Kg
Viral Load MA04d. Total
Suppressed Macerated still
during the month birth < 2.5 Kg
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HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 12
2.2 MATERNITY (continued) 2.2 MATERNITY (Continued) NUMBER
NUMBER Baby
MA27. Number received PNC
Total within 24 hours after birth Mother
MA05. Pre-Term births Alive
Oxytocin
< 2.5 Kg MA28. Uterotonics used in man- Misoprostol
Total agement of 3rd stage of labour
MA06. Born Before Arrival Alive Egometrine
< 2.5 Kg
2.3 POSTNATAL NUMBER
MA07. No. of low birth weight babies (<2.5 Kg)
Below 15 years
initiated on kangaroo (KMC)
MA08. Live babies at discharge 15-19 years
MA09. No. of Babies born with defect Age group 20-24 years
25-49 years
MA10. No. of Babies received LLIN PN01.Post Natal
50+ years
MA11. Newborn deaths (0-7 days) Attendances
24 Hours
MA12. Neonatal Death 8-28 days 6 Days
Timing
Below 15 years 6 Weeks
15-19 years 6 Months
PN02. Referrals to Total referrals
MA13. Maternal deaths 20-24 years
PNC unit From community services
25-49 years PN03. Breast feeding Total (TR & TRR)
50+ years mothers tested for
HIV 1st time during
Postnatal HIV+ (TRR)
MA14. No. of mothers who Total
initiated breastfeeding within PN04.Breastfeedng Total (TR+ & TRR+)
the 1st hour after delivery No. HIV + mothers re-tested for
HIV during Postnatal TRR+
MA15. Women tested for HIV in Total (TR & TRR) Total HIV+
labour 1st time this Pregnancy HIV+ (TRR) PN05. HIV+ women New Positives (TRR)
initiating ART in Positive on re-test (TRR+)
MA16. Women re-tested for Total (TR+ & TRR+) Postnatal
Positives but never initiated in
HIV in labour HIV+ (TRR+) ANC, Labour and Delivery (TRRK)
PN06.HIV+ breastfeeding mothers newly enrolled in
MA17. HIV+ women initiating ART in maternity MCH groups
PN07: Mother-baby pairs enrolled at Mother-Baby care
MA18. Male partners received Total (TR & TRR) point
HIV test results in the
maternity setting HIV+ (TRR) PN08. Male partners Total (TR & TRR)
received HIV
MA19. HIV+ male partners initiated on ART in test results in the
the maternity setting postnatal setting HIV+ (TRR)
MA20. Number of discordant couples identified PN09. HIV+ male partners initiated on ART in the
in maternity postnatal setting
PN10.Breast Total
Maternal Total feeding mothers
Nutritional given self-testing Tests returned HIV+
MA21. Mothers Received HIV+ kits for their male
nutrition Counselling partners Tests returned HIV negative
Infant Total
Feeding PN11. Number of discordant couples identified in PNC
HIV+
Clients screened for Cancer of
Total PN12. Cancer of the Breast
MA22. Deliveries to HIV+
the breast Clients with pre-malignant
women in unit Live births conditions of breast
Clients screened for Cancer of
Total number PN13. Cancer of the Cervix
MA23. HIV Exposed
infants given ARVs Number of high-risk the Cervix Clients with pre-malignant
infants 12 weeks conditions of cervix
MA24. No. of babies with Birth asphyxia PN14. Lactating mothers who received Total
Nutritional assessment HIV+
MA25: No. of Live babies Successfully
Resuscitated Total
PN15. Post- Maternal Nutritional
natal mothers HIV+
MA26. Number received Baby
PNC check at 6 hours who received Total
Counselling Infant Feeding
after birth Mother HIV+
Below 15 years
PHARMACIES/
DRUG SHOPS
NO. DISP. BY
NO. DISP. AT
NO. DISP. BY
NO. DISP. IN
OUTREACH
15-19 years 2.6.1 CONTRACEPTIVES
DISPENSED
FP11. 4 year implant 20-24 years
CBDs
UNIT
(e.g. Sino plant)
25-49 years
50+ years CT01. Oral: Lo-Femenal (cycles)
Below 15 years CT02. Oral: Microgynon (cycles)
15-19 years CT03. Oral: Ovrette or other POP (cycles)
FP12. 5 year implant 20-24 years CT04. Oral: Levonogesteral (cycles)
(e.g. Jadella)
25-49 years CT05. Oral: Emergency
contraceptives
50+ years
CT06. Oral: Others (cycles)
Below 15 years
15-19 years CT07. Female condoms (pieces)
FP13. IUD-Copper-T 20-24 years CT08. Male condoms (pieces)
25-49 years CT09: Injectable 3 months IM (doses)
50+ years CT10. Injectable 3 months SC (doses)
Below 15 years CT11. Injectable 2 months (doses)
15-19 years CT12. Injectable 1 month (doses)
FP14. IUD-Hormonal 20-24 years CT13. FAM-SDM (Cycle beads)
25-49 years (pieces)
50+ years CT14. IUDs–Copper T
Below 15 years CT15. IUDs –Hormonal
CT16. 3 year implant (e.g impalanon
15-19 years NXT, Levo plant)
FP15. FAM-SDM 20-24 years
method CT17. 4 year implant (e.g Sino plant)
25-49 years CT18. 5 year implant (e.g Jadella)
50+ years
2.6.2 MINOR OPERATIONS IN FAMILY PLANNING
Below 15 years
Below 15 years
15-19 years
FP16. FAM-LAM 20-24 years 15-19 years
25-49 years Timing 20-24 years
50+ years PFH01. No of 25-49 years
Below 15 years Mothers who
received family 50+ years
15-19 years
FP17. FAM-Two Days 20-24 years planning in Below 15 years
Method Postpartum by
25-49 years 15-19 years
50+ years Method 20-24 years
Below 15 years 25-49 years
15-19 years
FP18. Emergency 50+ years
Contraceptive Pills 20-24 years
users MF03-Implant removals
25-49 years
50+ years MF04-IUD removals
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HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 15
2.6.3 INTEGRATED SERVICES IN FAMILY PLANNING 2.6.4 POST PERTERM FAMILY PLANNING
Data Element NUMBER Less Than 48 hours
FH01. Number HIV+ FP Users 48hrs to 3 weeks
FH02. Number of FP Users screened for Cervical Cancer Timing 4weeks to 5weeks
FH03. STI screening in Total screened PFH01. No of 6 weeks to 5 months
Family planning Mothers who
Positive 6 months to 12 months
received family
planning in Oral formulation
Postpartum by
Injectable
Method implants
IUDs
Sterilization
3.0 HEPATITIS
<10yrs 10-19yrs 20-59yrs 60+ years
M F M F M F M F
HB01. Number of clients tested for HepB
HB05. Number tested positive for HepB and enrolled for treatment
HB06. Number tested positive for HepB and not enrolled into care and treatment
HB10. Number of pregnant women tested positive for HepB (Subset of row 4)
HB15. Number tested positive for HCV RNA and enrolled for treatment
Nutrition
New HIV positive
Unit
Linked to HIV care
Tested for HIV
STI Clinic New HIV positive
Linked to HIV care
Tested for HIV
Young
Child New HIV positive
Clinic
Linked to HIV care
Tested for HIV
ANC New HIV positive
Linked to HIV care
Tested for HIV
Maternity New HIV positive
Linked to HIV care
Tested for HIV
PNC New HIV positive
Linked to HIV care
Tested for HIV
Family New HIV positive
Planning
Linked to HIV care
Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of
individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals
Below 1yr 1–4 5-9 10 – 14 15 - 19 20 – 24 25 - 29 30 - 34 35 – 39 40 – 44 45 – 49 50+
M F M F M F M F M F M F M F M F M F M F M F M F
Tested for HIV
(by Entry Point for Health facility
HT01. Number of individuals
Health
New HIV positive
HT05. Number of
Testing approach
Facility
Linked to HIV care
Tested for HIV
Community New HIV positive
Linked to HIV care
HT06. Number of Individuals who received
HIV test results
HT07. Number of individuals tested for the first
time ever
HT08-Total Number of Individuals who tested
HIV positive (New + Known)
HT09 Number of newly Long-term infection
diagnosed HIV positive
individuals with a test
for recent infection result Recent infection
HT10. HIV positive individuals with
presumptive TB
HT11. Number of Individuals tested more than
once in the last 12 months
HT12. Number of individuals who were
Counselled and Tested together as a Couple
HT13. Number of individuals who were Tested
and Received results together as a Couple
HT14. Number of individuals with Concordant
positive results who tested as Couples
HT15. Number of individual with Discordant
results who tested as Couples
Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of
individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals
Below 1yr 1–4 5-9 10 – 14 15 - 19 20 – 24 25 - 29 30 - 34 35 – 39 40 – 44 45 – 49 50+
M F M F M F M F M F M F M F M F M F M F M F M F
+VE
-VE
SM01. Number of Males
Counselled and Tested for HIV at INC
SMC site
Known +VE
Not Tested
SC
SM02. Number of Males Facility
Circumcised (by Age Group- DC
Years) and Technique (SC
- Surgical SMC, DC - Device- SC
Based SMC) Outreach
DC
Facility Outreach
Technique
SC DC SC DC
Within 48 hours(0-48)
SM04. Number of males Circumcised who Returned for Follow Up
Within 7 days (>0-7)
Beyond 14 days
SM05. Number of males Circumcised who Experienced one or more Adverse Events Moderate
(Report only Moderate or Severe AEs) Severe
NUMBER
Quantity
Days out of Stock on Quantity
SN. NAME OF DRUG ITEM UNIT Consumed
stock hand expired
(units)
SS01 Artemether/Lumefantrine 20/120 mg Tablet
SS02 Depot medroxy progesterone acetate (DMPA) Injectable
SS03 Amoxicillin 250 mg capsule Capsule
SS04 Sulfadoxine/ Pyrimethamine tablet Tablet
SS05 ORS Sachets with zinc tablet Packet
SS06 Measles Vaccine Vial
SS07 Determine HIV 1 & 2 screening test Tests
SS08 Stat -pack HIV Confirmatory rapid tests, tests Tests
SS09 SD Bioline test Tie-Breaker Tests
SS10 CD4 reagent Tests
SS11 Malaria Rapid Diagnostic tests Tests
SS12 GeneXpert Cartridges Cartridges
SS13 Therapeutic milk F75 (75Kcal/100ml) Packet
SS14 Oral Liquid Morphine 5ml/ml Bottle of 500 ml
SS15 Ready to use Therapeutic feeds (RUTF) Sacket
SS16 TDF/3TC/EFV 300mg/300mg/(600mg or 400mg )tablet Pack of 30
SS17 AZT/3TC/NVP 300mg/150mg/200mg Pack of 60
SS18 Atazanavir /ritonavir (ATV/r) 300/100mg tablet Pack of 30
SS19 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30
SS20 TDF/3TC/DTG 300mg/300mg/50mg(TLD) Pack of 30
SS21 TLE 300mg/300mg/400mg Pack of 90
SS22 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg (Paediatric) Pack of 30
SS23 Lopinavir 40mg/ritonavir 10mg pellets in capsules Pack of 120
SS24 Cotrimoxazole 960mg tablet Pack of 1000
SS25 (RHZE) blister strip 150/75/400/275 mg 28 tablets
SS26 Blood 450 ml Unit
SS27 RHZ Blister 75mg/50mg/150mg 28 tablets
SS28 Misoprostol 200mcg Tablet** Tablet
SS29 Amoxicillin dispersible 250mg tablet. Tablet
SS30 Ceftriaxone 1g Injection Vial
SS31 Oxytocin Injection Ampoule
Chlorhexidine Digluconate Gel 7.1% (equivalent to 4%
SS32 Tube
chlorhexidine)
SS33 Mama Kit** Kit
SS34 Bendroflumethiazide (Aprinox) 5mg Tablet
SS35 Artesunate 60mg Injection
SS36 Nifedipine tablets 20mg tablet Tablet
SS37 Captopril 25mg tablet Tablet
SS38 Metformin 500mg Tablet
SS39 Glibenclamide 5mg tablet Tablet
SS40 Insulin short-acting Vial
SS41 Cardiac Aspirin 75/80 mg Tablet
LABORATORY
10.1.1. Total 10.1.2. Number of Specimen Collected at Facility and Received from other
number of laboratory client facilities (For tests done within)
visits
Blood Stool/ Urine Sputum CSF Pus Genital Skin Others
Rectal Swab Swab Snip
swab
LV01. SC01.
Outpatient Collected (IN)
(OPD)
LV02. SC02.
Inpatient Received
(IPD) (OUT)
Routine Test Type Reasons for Referrals and Reasons for not conducting tests that are on test menu
(specify type test)
Equipment Reagent Supplies Power No testing Lack of Confirmatory For QA Others
break down stock out stock out outage expertise required testing re-testing
equipment
RT01. CD4
RT02. TB
RT03. CBC
RT04. Chemistry
RT05. Microbiology
RT06. HIV screening
RT07. VDRL
RT08. Haematology
RT09. Parasitology
Staphylococcus
Campylobacter.
Escherichia coli
Salmonella spp
Vibrio cholera.
Streptococcus
Acinetobacter
Enterococcus
meningitides.
Haemophilus
gonorrhoeae
pneumoniae
pneumoniae
Shigella spp
baumannii
Organisms
Klebsiella
influenza.
Neisseria
Neisseria
aureus
Others
spp.
NP01. No. of Isolates
ANTIBIOTICS R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S
NP02. Ampicilin
NP03. Azithromycin
NP04.Amikacin
NP05.Ceftriaxone
NP06.Ceftazidime
NP07.Cefotaxime
NP08.Cefoxitin
NP09.Cefixime
NP10.Cotrimoxazole
NP11.Ciprofloxacin
NP12.Colistin
NP13.Gentamicin
NP14.Imipenem
NP15.Levofloxacin
NP16.Meropenem
NP17.Oxacillin
NP18.Penicillin G
NP19.Vancomycin
NP20. Augmentin
NP21.Chloramphenicol
NP22.Clindamycin
NP23.Erythromycin
NP24.Nalidixic acid
NP25.Nitrofurantoin
NP26.Piperacillin
NP27.Piperacillin/
Tazobactam
NP28.Tetracycline
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Date of Report:...................................................
Health Unit In-charge: Name:...............................................................................Title:................................Signature:...............................
Phone No.:........................................................ Email:................................................................................................................................
Date received
Received by 7th of next month Yes No
Checked by (signature)
Date Entered
Name of Data Entrant
COMMENTS BY HSD:................................................................................................................................................................................
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