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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

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Unit 12 reporting recording l.jpg

Unit 12: Reporting & Recording

Botswana National Tuberculosis Programme Manual Training for Medical Officers


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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


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Question

How are TB Prevention and Control

activities monitored and evaluated?

Unit 12: Reporting and Recording


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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


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Question

Why is accurate reporting

and record keeping important?

Unit 12: Reporting and Recording


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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


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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


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Botswana TB R&R Forms (1)

  • TB Suspect and Sputum Dispatch Register

  • Mycobacteriology Request Form

  • TB Laboratory Register

Unit 12: Reporting and Recording


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Botswana TB R&R Forms (2)

  • Facility/District TB Register

  • Patient Appointment and DOT Card

  • TB Contact Examination Form

Unit 12: Reporting and Recording


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Botswana TB R&R Forms (3)

  • Electronic TB Register (ETR)

  • Transfer of Patient

  • MDR Treatment Card

Unit 12: Reporting and Recording


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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


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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


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The TB Treatment Card (2)

Unit 12: Reporting and Recording


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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


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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


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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


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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


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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


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Pretreatment History and Clinical Findings

  • This section, below “Alternative address,” should be written in

  • There are no codes

Unit 12: Reporting and Recording


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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ART: Antiretroviral Therapy (2)

Example: The patient is not currently on ART; leave the ART status boxes blank

Unit 12: Reporting and Recording


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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


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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


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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


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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


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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


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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


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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


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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


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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


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Chest X-Ray (2)

Example: A patient has a cavity in the right upper lobe, according to his chest x-ray from 25 December, 2004, x-ray number 2234. This section would be completed as shown below

Unit 12: Reporting and Recording


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Culture and Sensitivity Report (1)

All re-treatment cases should submit a sputum specimen for culture and drug sensitivity testing

If a culture was performed, this section can be used to record the results of the drug sensitivity profile for each TB patient, along with the date

Unit 12: Reporting and Recording


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Culture and Sensitivity Report (2)

How to fill in this section:

Using the format “dd/mm/yy”, record the date in the appropriate column

If the sample is sensitive to a drug, mark the “Sensitive” column with an “X”

If the patient is resistant to a drug, mark the “Resistant” column with an “X”

Example:

A culture was performed for

a patient on 30 March, 2005

Result showed sensitivity

to all first-line drugs

Unit 12: Reporting and Recording


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Treatment Outcome (1)

Categorise the outcome of each TB patient at the end of treatment

How to fill in this section: Fill in the column with the appropriate outcome:

Cured

Treatment completed

Treatment failure

Died

Defaulted/interrupted

Transferred out

Unit 12: Reporting and Recording


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Treatment Outcome (2)

Example:

Francis Mulenga was initially smear-positive, but converted to smear-negative after two months of treatment

He had a smear-negative sputum result at 6 months.

Therefore he is considered cured; make an “X” over the box for cured

Unit 12: Reporting and Recording


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Remarks

This section records specific information not captured by any of the other sections about each TB patient

How to fill in this section: Following are examples of what can be written in this section:

“Patient’s wife is HIV positive”

“CD4 count = 50 on 12/03/05”

Example: Francis Mulenga’s wife is HIV-infected; record this information in the remarks section. This remark should also be a reminder that Francis should be offered another HIV test during his treatment

Unit 12: Reporting and Recording


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Preparing a TB Treatment Card Review

Were there any sections that were difficult to understand and fill out?

Do you have any other questions or concerns about the TB Treatment Card?

Unit 12: Reporting and Recording


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Key Points

Several approaches are used to monitor and evaluate the TB programme including, supervision, staff meetings, records and registers

Reporting and record keeping is important to the DOTS strategy

Good record keeping is vital to measuring success and motivating staff

Unit 12: Reporting and Recording


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