HOSPITAL TB REFERRAL LOGBOOK SUMMARY SHEET

Name of hospital: Reporting Period: / / to /

/_______
Location: Date Submitted:
Prepared by: Designation:
Reviewed by: Designation:
Reporting Quarter: _______________ Preceding
Quarter
Total no. of No. of No. of Internal TB cases Total no. No. of Cases not
referrals Total No. of bacteriogicall bacteriogicall Referrals referred TB cases No of TB of TB accepted referred
(presumptiv No. of TB y confirmed y confirmed that were No. of to registere cases cases and and
e TB/TB referrals patients cases cases confirme TB, all periphera d by started referred registere registere
patients) to from admitted referred to detected by d as TB forms l DOTS TDPH treatmen to d (with d (died,
hospital TB wards at the the hospital laboratory cases (7) facilities (manage t at the peripher TB case refused
team (2) ward TB team (5) (6) (external d by the ward al DOTS number) tx. Etc.)
(1) (3) (4) referral) TB (10) facilities at the (13)
(8) clinic) (11) periphera
(9) l DOTS
facility
(12)
Ref: Ref: Ref: Ref: column Ref: hosp. Ref: Ref: Ref: Ref: Ref:
Page Column 12 column hosp. 9 laboratory column 8 column column column column Ref: Preceding Quarterly Period
13 discharg register 10 16 15 14
e census
1
2
3
4
5
6
7
8
9
 10
Total