Standards and Guidelines for Electronic Medical Record Systems in ...

The 3 interlinked patient monitoring systems support integrated service provision, follow-up of
mother-infant pair and monitoring of key TB-related and pediatric variables.
Both the ART Patient Monitoring guidelines and the 3 interlinked Patient Monitoring System forms
booklet provide, in detail, the minimum data that each EMR system should collect for the provision
of care in a HIV clinic. They also define the different data elements to be collected and offer
guidance on when the data is collected; at enrollment, once during HIV care or repeated at every
clinic encounter. EMR systems are required to collect data as defined by the guidelines.
These guidelines and booklet can be downloaded for reference from the WHO, NASCOP and MOH
websites:
· www.who.int
· www.aidskenya.org
· http://www.publichealth.go.ke
The following is a summary of the essential list of data elements that every EMR must collect for
HIV care. (Adapted from the summary list in the Patient Monitoring Guidelines)
Demographic Information
· Unique ID number, patient clinic ID number
· Name, sex, date of birth, age at registration, marital status
· Address, telephone, contact information
HIV Care and Family Status
a) Date and location confirmed HIV-positive, HIV subtype
b) Entry point into HIV care
c) Current health facility, district, district clinician/team
d) Treatment supporter(s) name/address/contact information
e) If family members/partners: name, HIV status, HIV care status, unique ID number, date of birth/age at
registration
f) Drug allergies
ART Summary
· ART history prior to entry
· ART START date/treatment cohort:
Standards and Guidelines for Electronic Medical Records Systems in Kenya 34