Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

13. For vaccine-preventable diseases such as measles, meningitis and yellow fever, obtain the patient’simmunization history for the reported illness. Record the number of vaccine doses received by patientfor that illness and the date of the last immunization dose. Do not count doses that were received withinthe last 15 days. If the immunization was received within the last 15 days, there may not have been animmunization response.For meningitis, record if there is a history of vaccination during a mass campaign.14. Record information on laboratory tests. Record the date specimen was taken. If no specimen is taken“NA” for Not Applicable. Also record the results of the laboratory tests carried out by indicating “+ve”for positive results and “-ve” for negative, “Ind” for indeterminate results and “NA” for not applicable, ifno specimen was taken.15. Record the outcome of the case at the time of reporting. Indicate the status of the patient with “A” foralive, “D” for dead, “R” for referred and “U” for when status of patient is unknown.16. Record any comments. This could include remarks such as “sister to case no. RRR-DDD-YY-002”.Other comments could include specimen condition and the serotype of pathogen. Where the status of acase previously reported is being updated, the remark “updated record” should be noted.17. The name and signature of the person completing the form should be recorded.152Technical Guidelines for Integrated Disease Surveillance and Response in Ghana