Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

Annex 7Maintaining Clinic Registers for Recording PriorityDiseases and ConditionsEach health facility should maintain registers for recording cases of priority diseases and conditions seenin the health facility. At a minimum, the clinic register should have spaces for recording the following information:Outpatient The patient’s serial number The patient’s name The patient’s age The patient’s sex The patient’s address (residence/town) The patient’s principal diagnosis Other diagnoses Laboratory results, if case was confirmed with laboratory specimen The date the patient was seen The patient’s treatment or outcomeRemarks relevant to patient’s disease, treatment or outcomeInpatient The patient’s serial number The patient’s name The patient’s age The patient’s sex The patient’s address (residence/town) The patient’s principal diagnosis Other diagnoses Laboratory results, if case was confirmed with laboratory specimen The date the patient was admitted The date the patient was discharged Treatments the patient received Surgical procedures the patient received Cost of treatment Outcome of admission (alive, dead, absconded, referred, unknown)Remarks relevant to patient’s disease, treatment or outcomeAnnex 7: Maintaining Clinic Registers for Recording Priority Diseases and Conditions 141