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EMT-MDS Daily Reporting Form

Ver 2019 WHO

a Organization name: Universitas Brawijaya h Date of activity (dd/mm/yyyy): 18/10/2022

Time of reporting
Team information
b Team name: Tim Medis UB - PKM Sitiarjo i
(dd/mm/yyyy/hh:mm(24h)):
18/10/2022/19:13
Type 1 mobile Type 1 fixed Type 2 Type 3 Specialized cell Location †
☑ □ □ □ □
c
j State etc. (admin1) Jawa Timur
d Contact Person(s) name(s): dr Aurick Yudha, Sp.Em., KEC k City etc. (admin2) Kabupaten Malang
e Phone No.: l Village etc. (admin3) Desa Sitiarjo, Kec. Sumbermanjing Wetan
f Email: m Facility name: Krajan Kidul
g Estimated date of departure 17/10/2022 n Geo-tag 7.96 111.31
(dd/mm/yyyy): (Lat) (Long)
† Submit one form per one activity day and location. For Admin 1 = e.g. State, Province, Governorate;
Admin 2 = e.g. County, District, City, Municipality; Admin 3 = e.g. Sub-district, Village, Payam.
Number of patient / Bed Count
Discharge without medical follow-
o Total Number of new consultation‡ 67 36 64 44 Directly related to event 0
up

Relation
Patients
Daily Summary

MDS statistics ‡
p New admission (=MDS40) 0 37 Discharge with medical follow-up 1 45 Indirectly related to event 26

q Live Birth 0 38 Discharge against medical advice 0 46 Not related to event 48

Outcome
r Total bed capacity 0 39 Referral 0 47 Vulnerable child * 0

Protection
Bed

s Empty inpatient bed (Non-ICU) 0 41 Dead on arrival 0 48 Vulnerable adult * 0

Sexual Gender Based Violence
t Empty Intensive Care Unit Bed (ICU) 0 42 Death within facility * 0 49 0
(SGBV) *
Requiring long term rehabilitation
u 43 0 50 Violence (non-SGBV) * 0
*
‡Consider 24 hours period from midnight or other agreed cut off time for reporting. MDS statistics report outpatient consultations, inpatient admissions, as well as preformed procedures
(MDS No.30-35), outcomes (MDS 36-43) and contextual issues (MDS No.44-50) newly counted during the reported period. MDS No.43 is a subset of MDS No.37-38. MDS No.47-50 are a
No Age Categories <1 y.o. 1-4 y.o. 5-17 y.o. 18-64 y.o. 65- y.o. Total Needs and Risks
Demographic

statistics

1 Male 0 1 2 9 11 23 Free text reporting to EMTCC / MOH on the following issues.

Sex & Age
MDS

Female non-
2
preg.
0 0 2 32 10 44 51 Unexpected death * □
Female
0 0 0 0 □

Immediate
3 52 Notifiable disease *
pregnant

report
53 Protection issues # □
No Health Events < ５ y.o. >=5 y.o. Total 54 Critical incident to EMT and/or community □
4 Major head / spine injury 0 0 0 55 Any other issue requiring immediate reporting □
5 Major torso injury 0 0 0 56 WASH ☑
Community Risks
Trauma

6 Major extremity injury 0 0 0 57 Community / suspected over infectious disease □

7 Moderate injury 0 0 0 58 Environmental risk / exposure □
8 Minor injury 0 3 3 59 Shelter / Non food items □
9 Acute respiratory infection 0 15 15 60 Food insecurity □
10 Acute watery diarrhea 0 0 0 61 Logistics / operational support ☑
□
Operational

Acute bloody diarrhea 0 0 0

constraints

11 62 Supply
Infectious disease

12 Acute jaundice syndrome 0 0 0 63 Human resources □

13 Suspected measles 0 0 0 64 Finance □
14 Suspected meningitis 0 0 0 65 Others ☑
15 Suspected tetanus 0 0 0 Detailed comment for ( No. 65 )
Health Events and Procedure

16 Acute flaccid paralysis 0 0 0 We are planning to start mobile EMT services.

17 Acute haemorrhagic fever 0 0 0

MDS statistics

18 Fever of unknown origin 1 0 1

19 Myalgia, Athralgia, OA 0 22 22
Additional §

20 HT, Metabolik Sindrom, 0 14 14

Detailed comment for ( No. 56 )
21 Dispepsia, nausea, vomiting 0 7 7
Butuh air bersih untuk kebutuhan harian di rumah warga
22 Hernia 0 1 1

23 Surgical emergency (Non-trauma) 0 0 0

Emrg.

24 Medical emergency (Non-infectious) 0 0 0

25 Skin disease 0 19 19
Other key diseases

26 Acute mental health problem 0 1 1 Detailed comment for ( No. 61 )

27 Obstetric complications 0 0 0 obat jamur, vitamin anak

28 Severe Acute Malnutrition (SAM) * 0 0 0

29 Other diagnosis, not specified above 0 0 0

Procedure <5 y.o. >=5 y.o. Total

30 Major procedure (excluding MDS31) 0 0 0

Detailed comment for ( No. )
31 Limb amputation excluding digits * 0 0 0
Procedure

32 Minor surgical procedure 0 1 1

33 Normal Vaginal Delivery (NVD) 0 0

34 Caesarean section 0 0

35 Obstetrics others 0 0
* Line list (including detailed information) should be submitted with this MDS form to relevant authorities. § Additionals are used for context specific reporting items indicated by the relevant
authorities e.g. Malaria / Dengue / TB / Leptospirosis / Rabies / Hazmat etc. # Protection issues to be reported confidentially to appropriate authority or protection cluster in locally agreed