How to investigate Adherence to Antiretroviral Treatment ... - INRUD

How to Investigate Adherence to Antiretroviral Treatment in Health Facilities: Adherence Indicators
Table 7. Example of a Completed Retrospective Form
H
100 Retrospective Dispensing Data FACILITY # Data Collector
For 100 patients who visited clinic during the month that occurred 7 months ago, record dates and details for that index visit and for all clinic or pharmacy visits since that time.
Date of Entry: FACILITY N Name Data
A B C D E G H J K N O R S V W Z AA AD AE
Initiation of
ARVs
Index Visit Dispensing Visit 2 Dispensing Visit 3 Dispensing Visit 4 Dispensing Visit 5 Dispensing Visit 6 Dispensing Visit 7 Dispensing
Age in Yrs at
index visit
Gender
M/F
Seq.
No.
Patient
identifier
Print Retro
Date
initiation
ARVs
Index visit
Date any
ARV drugs
dispensed
(dd/mm/yy)
# days of
ART
dispensed on
that day
Date any
ARV drugs
dispensed
(dd/mm/yy)
# days of
ART
dispensed on
that day
Date any ARV
drugs
dispensed
(dd/mm/yy)
# days of
ART
dispensed on
that day
Date any
ARV drugs
dispensed
(dd/mm/yy)
# days of
ART
dispensed on
that day
Date any
ARV drugs
dispensed
(dd/mm/yy)
1 1515 29 F 05-Oct 12-Nov 30 6-Dec-06 30 5-Jan-07 60 5-Mar-07 30 5-Apr-07 90
# days of
ART
dispensed on
that day
Date any
ARV drugs
dispensed
(dd/mm/yy)
# days of ART
dispensed on that
day
Date any
ARV drugs
dispensed
(dd/mm/yy)
2 32 26 F 24-Sep 08-Nov 30 12-Dec-06 30 10-Jan-07 30 9-Feb-07 30 3-Jul-07 30 10-Apr-07 30 11-May-07 30
3 1157 14 M 17-Jan 08-Nov 60 5-Jan-07 90 3-Apr-07 90
4 2384 8 M 03-May 08-Nov 60
5 2428 54 F 10-Oct 08-Nov 30 6-Dec-06 30 5-Jan-07 60 6-Mar-07 90 6-Jun-07 90
6 2233 36 M 08-Nov 08-Nov 30 6-Dec-06 30 4-Jan-07 30 31-Jan-07 30 2-Mar-07 30 29-Mar-07 30 25-Apr-07 30
7 285 36 M 09-Nov 29-Nov 90 27-Apr-07 30 26-May-07 30
8 1570 49 F 12-Apr 09-Nov 30 6-Dec-06 90 6-Dec-06 90 9-Mar-07 90
9 475 41 M 21-Jun 09-Nov 30 11-Dec-06 30 10-Jan-07 30 8-Feb-07 30 13-Mar-07 30 12-Apr-07 60 7-Jun-07 30
10 1627 33 F 28-Jun 09-Nov 30 12-Mar-07 30
11 289 37 M 01-Nov 01-Nov 90 1-Feb-07 90 30-Apr-07 90
12 2501 24 F 02-Nov 02-Nov 30 30-Nov-06 30 1-Jan-07 30 29-Jan-07 30 28-Feb-07 60 27-Apr-07 60
13 82 30 F 04-Oct 01-Nov 30 16-Nov-06 15 28-Nov-06 30 29-Dec-06 30 25-Jan-07 90 26-Apr-07 90
14 358 39 M 14-Oct 02-Nov 90 2-Feb-07 90
15 873 41 F 06-Jan 02-Nov 90 2-Feb-07 180 4-May-07 90
16 1003 26 F 13-Jul 02-Nov 90 31-Jan-07 90 2-May-07 90
17 1035 31 F 08-Mar 02-Nov 90 31-Jan-07 90 2-May-07 90
18 1351 36 F 08-Jul 02-Nov 90 4-Dec-06 60 1-Feb-07 90 2-May-07 90
19 2331 31 F 13-Aug 02-Nov 90 1-Feb-07 30 7-Mar-07 120 4-May-07 90
20 2714 38 F 04-Mar 02-Nov 90 23-Jan-07 90 30-Mar-07 90
21 702 36 F 16-Nov 03-Nov 90 1-Feb-07 90 2-May-07 180
22 2157 27 F 14-Jul 03-Nov 60 2-Jan-07 60 1-Mar-07 90 7-Jun-07 90
23 2343 45 M 14-Aug 03-Nov 60
24 1640 25 F 11-Apr 03-Nov 90
25 2716 34 M 03-Nov 03-Nov 30 16-Nov-06 30 21-Dec-06 30 16-Jan-07 60 13-Apr-07 60 17-May-07 60
# days of
ART
dispensed on
that day
34