Unit 12: Reporting & Recording

Unit 12: Reporting & Recording Botswana National Tuberculosis Programme Manual Training for Medical Officers

Objectives At the end of this unit, participants will be able to: • Discuss the importance of collecting data • Explain the ways in which data are used • Describe details for completing each reporting form • Practice completion of the Botswana Treatment Card Unit 12: Reporting and Recording

Question How are TB Prevention and Control activities monitored and evaluated? Unit 12: Reporting and Recording

Monitoring & Evaluation Activities Completing reporting forms on case findings and treatment outcomes Supervisory visits Discussions during staff meetings Review of medicine stocks Staff training Follow-up Analysing data collected Unit 12: Reporting and Recording

Question Why is accurate reporting and record keeping important? Unit 12: Reporting and Recording

Importance of Reporting and Record Keeping It is an important part of the DOTS strategy It helps clinics, regions and the nation reach its programme goals It helps us know if our strategies are effective It allows us to see trends and to identify “hot spots” or high risk groups so that efforts can be targeted Unit 12: Reporting and Recording

Data Can Enhance Your Work By… Serving as positive reinforcement for a job well done Motivating staff to continue or improve their efforts Identifying areas of strengths and weaknesses Identifying training and supervision needs Unit 12: Reporting and Recording

Botswana TB R&R Forms (1) • TB Suspect and Sputum Dispatch Register • Mycobacteriology Request Form • TB Laboratory Register Unit 12: Reporting and Recording

Botswana TB R&R Forms (2) • Facility/District TB Register • Patient Appointment and DOT Card • TB Contact Examination Form Unit 12: Reporting and Recording

Botswana TB R&R Forms (3) • Electronic TB Register (ETR) • Transfer of Patient • MDR Treatment Card Unit 12: Reporting and Recording

Botswana TB R&R Forms (4) • MDR Treatment Register • IPT Dispensary Tally Sheet • IPT Register and Compliance Record • Tuberculosis Treatment Card Unit 12: Reporting and Recording

The TB Treatment Card (1) Initial source of data for the TB recording and reporting system Diagnosis and treatment information Should be completed by MDs and nurses Information from the treatment card is used to fill in the facility and district TB registers Information should be complete and accurate SOME data is better than NO data!! Unit 12: Reporting and Recording

The TB Treatment Card (2) Unit 12: Reporting and Recording

Name (Surname, First Name) The patient’s surname is written first, followed by the patient’s first name. If the patient has a middle name, write that in the space as well. Example: The patient’s name is Francis Mulenga Unit 12: Reporting and Recording

Sex Circle the appropriate box for either male (M) or female (F) Example: Francis Mulenga is male, “M” should be recorded Unit 12: Reporting and Recording

Age (in years) Correct response for this column is age in years. If patient is a child under one year old, write the number of months followed by /12 (e.g., 6 months would be 6/12) If the patient doesn’t know their age: Look on the OPD Ask year of birth Ask a family member Unit 12: Reporting and Recording

Omang/Passport # Fill in the 9-digit Omang number or Passport number of each TB patient in the space provided. If the patient does not have an identification number, leave this column blank. Example: Francis Mulenga’s Omang number is 123456789 Unit 12: Reporting and Recording

Address in Full The best description of where the patient lives should be written in this section (street address or plot number). The HCW needs to know enough to FIND the person if s/he has to!! Example: Francis Mulenga lives in a blue house near the Shell petrol station in plot 45 Request at least one mobile phone number for patient and close relative Unit 12: Reporting and Recording

Pretreatment History and Clinical Findings • This section, below “Alternative address,” should be written in • There are no codes Unit 12: Reporting and Recording

Registration and Transfer Information Unit TB No: The Unit TB number consists of four parts A: District Number (2 digits) B: Health facility Code number (3 digits) C: Specific serial number of the patient starting with 001 at the beginning of each year D: Year of registration Unit 12: Reporting and Recording

Transfer Information (1) Transferred/Moved Out: • If a patient transfers to a facility in another district during treatment (“transfer out”), or moves to another facility in the same reporting unit (“move out”), fill in the “To” column with the name of the health facility to which the patient transferred/ moved • A separate BNTP form entitled Notice of Transfer of a Patient must be completed for all patients transferring or moving Unit 12: Reporting and Recording

Transfer Information (2) Example: a patient with registration number “089/04” was moved out to Ext. 14 Clinic on 02 October 2004. Unit 12: Reporting and Recording

Transfer Information (3) Transferred/Moved In: Patients transferred or moved in from another reporting unit to your health facility, should be (re-)registered in the TB register. Enter your unit TB number, along with the patient’s new registration number, in the second line of the box. Put an “X” in the “IN” column Note that this is a duplicate TB treatment card, as the original card remains at the original health facility Unit 12: Reporting and Recording

Transfer Information (4) The receiving clinic must complete the Response to a Transfer of a Patient and return to sending clinic. Unit 12: Reporting and Recording

Transfer Information (5) Do not fill in the “REGISTERED” column– it is just to state that the patient has been registered in your health facility. Record the date that the patient came into health facility Example: the patient was re-registered with the new registration number “078/04”, when he moved in to Ext. 14 Clinic on 15 October 2004 Unit 12: Reporting and Recording

TB Classification (1) Purpose: Disease classification and site of disease should be recorded in this section Pulmonary disease means TB of the lungs, including patients that are smear-positive or smear-negative All other types of TB are classified as extrapulmonary disease, including pleurisy and miliary TB Patients with pulmonary AND extrapulmonary disease should be classified as pulmonary Unit 12: Reporting and Recording

TB Classification (2) Make an “X” over the appropriate box for pulmonary TB or extrapulmonary TB If the patient has both pulmonary and extrapulmonary TB, mark this as pulmonary TB and fill in the site of extrapulmonary TB In the case of extrapulmonary TB, indicate the site that has been affected in the space provided Example: Francis Mulenga has pulmonary TB Unit 12: Reporting and Recording

Patient Category Proper patient category necessary to determine appropriate treatment regimen Make an “X” over the box with the appropriate option. The four options are: NEW FAILURE DEFAULT RELAPSE Francis Mulenga is a new patient RETREATMENT CASES Unit 12: Reporting and Recording

Sputum Examination Results: Pre-Treatment (1) Purpose: These columns record the date and results of the patient’s pre-treatment sputum smear result In all cases (except young children), three sputum examinations should be done (spot, morning, spot) Unit 12: Reporting and Recording

Sputum Examination Results: Pre-Treatment (2) Date format: “dd/mm/yy” Record date of collection of sputum Results column: “P” for positive and “N” for negative Indicate the grading of the sputum result (i.e., scanty, +, ++, +++) Unit 12: Reporting and Recording

Sputum Exam Results: Pre-Treatment (3) Example: Francis Mulenga gave three sputum specimens for examination, one on 12th January and two on 13th January The results were “+++”, “++”, and “+++”, respectively Unit 12: Reporting and Recording

Sputum Exam Results: Intensive Phase (2 Month Exam) (1) Purpose: Two sputum smears should be done after two months of treatment Unit 12: Reporting and Recording

Date format: “dd/mm/yy” Record date of collection of sputum Results column: “P” for positive and “N” for negative Example: Francis Mulenga gave one sputum specimen for examination on 15th March. The result was negative Sputum Exam Results: Intensive Phase (2 Month Exam) (2) Unit 12: Reporting and Recording

Sputum Exam Results: End of Treatment (6 months) Two sputum exams should be done at the end of six months of treatment Date format: “dd/mm/yy” Record date of collection of sputum Results column: “P” for positive, “N” for negative Example: Francis Mulenga gave two sputum specimens for examination on 5th July. Results were negative Unit 12: Reporting and Recording

Sputum Smear Results:End of Treatment (8 months) Category II patients should have two sputum examinations at eight months Date format: “dd/mm/yy” Record date of collection of sputum Results column: “P” for positive, “N” for negative Unit 12: Reporting and Recording

Pre-Treatment Weight This section records the patient’s weight prior to treatment, in kilograms Weigh the patient, record the value in the space provided Weight is essential to determine drug dosages Unit 12: Reporting and Recording

Initial Phase of Treatment Lists the fixed-dose combinations of anti-TB drugs for adults and children during the intensive phase of TB treatment Circle the anti-TB regimen that the patient is taking Example: Francis Mulenga weighs 58 kg, so he will receive the regimen circled Unit 12: Reporting and Recording

HIV Status (1) This section records up to two HIV test results for each TB patient Patients with a negative test result at the beginning of treatment should be re-tested within three months or before the end of treatment Unit 12: Reporting and Recording

HIV Status (2) Example: Francis Mulenga was tested HIV negative on 15 January 2005; make an “X” over the box indicating a negative result and record the date Francis Mulenga was retested two months later and had a positive test result; make an “X” over the box indicating a positive result and record the date 15/03/05 X Unit 12: Reporting and Recording

ART: Antiretroviral Therapy (1) This section records TB patient history of, or concurrent treatment with ART, along with the date Make an “X” over the appropriate box If the patient is on ART, or has a history of taking ART, make an “X” in the “Yes” box If the patient is HIV negative, leave the box blank If the patient is HIV-infected, but is not on ART, leave the box blank Using the format “dd/mm/yy”, record the date in the appropriate column Unit 12: Reporting and Recording

ART: Antiretroviral Therapy (2) Example: The patient is not currently on ART; leave the ART status boxes blank Unit 12: Reporting and Recording

IPT (1) This section records whether the TB patient has received IPT prior to the current TB episode, along with the date IPT started Make an “X” over the appropriate box If the patient has ever taken even one dose of IPT as part of the IPT programme , make an “X” in the “Yes” box If the patient has never taken IPT, make an “X” in the “No” box Using the format “dd/mm/yy”, record the date in the appropriate column Unit 12: Reporting and Recording

IPT (2) Example: The patient received 3 months of IPT prior to developing TB; mark an “X” over the “YES” box on the treatment card X 15/03/05 X 01/06/03 Unit 12: Reporting and Recording

Other Tests: Biopsy, PPD, Other This section records other test results for each TB patient, along with the date. Not all TB patients will have other tests, so this section may be left blank if it is not applicable Example: Francis Mulenga had a PPD result of 18 millimeters on 15 January 2005, but did not have a biopsy Unit 12: Reporting and Recording

Treatment Compliance To track patient adherence to anti-TB treatment on a daily basis. Records follow-up weight at end of each calendar month HCW should enter his/her initials on each day of supervised drug administration, a “-“ for self-supervised treatment, or a “0” for any missed treatment Example: Francis Mulenga began DOT on 15 January 2005, but on 22 January, he was unable to visit the clinic and missed that day of treatment. His follow-up weight at the end of January was 59.2 kilograms Unit 12: Reporting and Recording

Continuation Phase (1) This section lists the fixed-dose combinations of anti-TB drugs for adults and children during the continuation phase of treatment Record the patient’s follow-up weight Circle the anti-TB regimen that the patient is taking Unit 12: Reporting and Recording

Continuation Phase (2) Example: Francis Mulenga weighs 59.4 kg at the continuation phase of treatment, so he will receive the regimen circled Unit 12: Reporting and Recording

Contact Screening (1) This section records the number of people that the TB patient thinks s/he has come in contact with, along with the number of contacts screened for TB Record the number of people that the TB patient thinks they have come in contact with in the first column Of these people, record the number of contacts that have been screened using the BNTP screening form Unit 12: Reporting and Recording

Contact Screening (2) Example: Francis Mulenga thinks he came in contact with 5 people Of these, 3 people have been screened for TB Unit 12: Reporting and Recording

Chest X-Ray (1) Record results for up to two chest x-rays, along with the date of the chest x-ray How to fill in this section: Record the chest x-ray number in the first section Draw any abnormalities in the corresponding location on the picture of the lungs Using the format “dd/mm/yy,” record the date in the appropriate column Unit 12: Reporting and Recording

Unit 12: Reporting & Recording