A.

ANC/PMTCT

Month……………………Year………………………..

Data element Value

New ANC clients
Re-Visit ANC Clients
Clients given IPT 1st Dose
Clients given IPT 2nd Dose
Clients given IPT 3rd Dose
Clients with Hb <11g/dl
Pregnant women completing 4 ANC visits
Pregnant women completing 8 ANC visits
LLITN distributed to children <1 year
LLITNs distributed to ANC clients
ANC clients tested for syphilis
ANC clients Syphilis +ve
Total Women Done Breast Examination
No. Adolesc. (10-14 years) Pregn. At 1st ANC Visit
No. Adolesc (15-19 years) Preg At 1st ANC Visit
Youth (20-24 years) presenting with pregnancy at 1st ANC Visit
Women presenting with pregnancy at 1st ANC in the First Trimeseter(<= 12 Wks)
ANC Client given Iron
ANC Client given folic
ANC Client Supplemented with Combined Iron and Folate
Pregnant women presenting in ANC with complication associated with FGM

PNC Women counselled on Post Partum FP

PNC clients who received Post Partum FP
Mothers receiving Postpartum Care within 48 hours
Mothers receiving Postpartum Care 3 days to 6 weeks
Mothers receiving Postpartum Care after 6 weeks
Infants receiving Pospartum care within 48 hours
Infants receiving Pospartum care Between 3 days to 6 weeks
Infants receiving Pospartum care after 6 weeks
PNC fistula cases
PNC referals From Community Unit

Compiled By……………………………………….Signature
B. Maternity and Newborn
Month…………………………….Year………………….
Data element Value
Normal Deliveries
Caesarian Sections
Breach Delivery
Assisted vaginal delivery
Mothers given uterotonics within 1 minute (Oxytocin)
Mothers given uterotonics within 1 minute (Carbatosin)
Live birth
Low Birth Weight <2500gms
Low UPGAR score
Birth with diformities
Total given CHX
Neonates given Vit "K"
Babies applied chlorhexidine for cord care
Neonates 0 -28 days put on Continous Positive Airway Pressure(CPAP)
Babies given tetracycline at birth
Pre-term babies
NBU Babies Adm/Disc/Death
Babies discharge Alive
Infants intiated on breast feeding within 1 hour after birth
Deliveries from HIV+ve Women
Fresh Still Birth
Macerated still Birth
Perinatal Deaths 0-7 days
Neonatal deaths 0-28 Days
Maternal deaths 10-14Years
Maternal deaths 15-19Years
Maternal deaths 20-24 Years
Maternal deaths 25+ Years
Maternal Deaths Audited Within 7 Days
Neonatal deaths audited within 7 days
Live Dead
A.P.H
P.P.H
Eclampsia
Raptured Uterus
Obstrucred Labour
Sepsis
Mothers with delivery complications associated with FGM
Neonatal deaths due to Sepsis
Neonatal deaths due to Prematurity
Neonatal deaths due to Asphyxia
Neonates initiated on skin to skin Mother Care
Children under five years with severe pneumonia treated with Oxygen
Maternal Referrals From Community Unit
Adolescent (10-19yrs) accessing PAC services
Youth 20-24 yrs receiving PAC services
Receiving PAC 25yrs plus
Total Admissions(MOH301)
Total Discharges(MOH301)
Refferals Out Of the facility
Admission due to Malaria in Pregnancy
PNC Clients New
PNC Clients revisits
PNC Women counselled on Post Partum FP
PNC clients who received Post Partum FP
Mothers receiving Postpartum Care within 48 hours
Mothers receiving Postpartum Care 3 days to 6 weeks
Mothers receiving Postpartum Care after 6 weeks
Infants receiving Pospartum care within 48 hours
Infants receiving Pospartum care Between 3 days to 6 weeks
Infants receiving Pospartum care after 6 weeks
PNC fistula cases
PNC referals From Community Unit
C. Sexual and Gender Based Violence Age SGBV

Month………………………………Year………………..

Data element 0-9 yrs 10-17 yrs 18-49Yrs 50 Yrs an Total

SGBV Total Survivors Seen
SGBV cases presenting within 72 hours
SGBV Eligible Survivors Initiated on PEP
SGBV Eligible Survivors Completed PEP
SGBV Rape surviors seroconverting 3 months after exposure
SGBV Survivors eligible for ECP
SGBV Survivors receiving ECP
SGBV Rape/defilement survivors pregnant 4 weeks after exposure
SGBV RC/IPV clients seen
SGBV Survivors with disability

Compiled By………………………………Signature…………………
F. Child Health and Nutrition Information System (CHANIS) Gender

Holy Family Nangina Mission Hospital

Data element Female Male Total

Normal Weight for Age 0-<6 months
Underweight 0-<6 months
Severely underweight 0-<6 months
Overweight 0-<6 months
Obese 0-<6 months
Normal Weight for Age 6-23 months
Underweight 6-23 months
Severely underweight 6-23 months
Overweight 6-23 months
Obese 6-23 months
Normal Weight for Age 24-59 Months
Underweight 24-59 Months
Severely underweight 24-59 months
Overweight 24-59 months
Obese 24-59 months
MUAC 6 - 59 months Normal (Green)
MUAC 6 - 59 months Moderate (Yellow)
MUAC 6 - 59 months Severe (Red)
0-59 months Normal Height for Age
0-59 months Stunted
0-59 months Severely Stunted
New Visits of 0-59 Month Attending CWC
Kwashiorkor
Marasmus
Faltering Growth
Exclusive breastfeeding 0-<6 months
De-wormed 12-59 Months
Children aged 6-23 months supplemented with MNPS
Children under five years with diarrhea treated with ORS and Zinc (Co-pack)
Children under five years presenting with pneumonia treated with Amoxycillin (DT)
Children under five deaths
Under 5 Years with any Kind of Disability
Children under five years with delayed developmental milestones
New RevisitTotal
Nutrition Clinic
F1. CHANIS Under Five Years default

Holy Family Nangina Mission Hospital December 2020

Data element Value

Children under five years with diarrhea treated with ORS and Zinc (Co-pack)
Children under five years presenting with pneumonia treated with Amoxycillin (DT)
Children under five deaths
Under 5 Years with any Kind of Disability
Children under five years with delayed developmental milestones
G. Cervical cancer screening Age_cx

Holy Family Nangina Mission Hospital November 2020

Data element <25 yrs 25-49 yrs 50 Yrs and Total

Cervical cancer receiving VIA /VILI /HPV VILI / HPV
Cervical cancer clients screened for Pap smear
Cervical cancer clients screened for HPV test
Cervical cancer clients with Positive VIA/VILI result
Cervical cancer clients with Positive Cytology result
Cervical cancer clients with Positive HPV result
Cervical cancer clients with suspicious cancer lesions
Cervical cancer clients treated using Cryotherapy
Cervical cancer treated using LEEP
HIV positive clients screened for cervical cancer

Compiled By………………………………………….Sign…………………….
H. Post Natal Care (PNC) default

Month………………………………Year……………..

Data element
PNC Clients New
PNC Clients revisits
PNC Women counselled on Post Partum FP
PNC clients who received Post Partum FP
Mothers receiving Postpartum Care within 48 hours
Mothers receiving Postpartum Care 3 days to 6 weeks
Mothers receiving Postpartum Care after 6 weeks
Infants receiving Pospartum care within 48 hours
Infants receiving Pospartum care Between 3 days to 6 weeks
Infants receiving Pospartum care after 6 weeks
PNC fistula cases
PNC referals From Community Unit

Compiled By……………………………………Sign…………….
Value
J. Mental Health default

Holy Family Nangina Mission Hospital December 2020

Data elemeValue
Psycho-Social Counselling
Alcohol and Drug Abuse
Bipolar Disorders
Depression
Schizophrenia and Pyschotic Disorder
Psycho-Social Assessments and Invest.
Psycho-Social Rehabilitation
Outreach Services / Health Talks
Mental Health Referrals
K. Physiotherapy Service Physiotherapy Services

Holy Family Nangina Mission Hospital December 2020

Data elemeNew Visits Revisits No of trea FIF Collect Total

Clients with neurological disorders receiving physiotherapy
Clients with peripheral nerve disorders attending physiotherapy
Clients with post traumatic injuries attending physiotherapy
Clients with degenerative orthopedic disorders attending physiotherapy
Clients with Cardio-respiratory disorders receiving physiotherapy
Women of reproductive age attending pre and post natal physiotherapy
K1. Other FIF default

Holy Family Nangina Mission Hospital December 2020

Data element Value

Amount of FIF Collected
Amount of FIF Waived
Amount of FIF Exempted
K2. TB Screening default

Holy Family Nangina Mission Hospital December 2020

Data elemeValue
Total Screened for TB
Total Presumptive TB Cases
Total already on TB Treatment
Total Not Screened for TB
Report received from facility default

Holy Family Nangina Mission Hospital December 2020

Data elemeValue