HOSPITAL TB REFERRAL LOGBOOK SUMMARY SHEET

Reporting Period: / / to /
Name of hospital: SIMBULAN SANTO NIÑO HOSPITAL /_______
Location: DON CARLOS BUKIDNON Date Submitted:
Prepared by: SHELLA MAE B. CABREZOS, RN Designation: TB-NURSE
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 referred cases detected confirme TB, all periphera d by started referred registered registere
patients) to from admitted to the by laboratory d as TB forms l DOTS TDPH treatment to (with TB d (died,
hospital TB wards at the hospital TB (5) cases (7) facilities (manage at the periphera case refused
team (2) ward team (6) (external d by the ward l DOTS number) tx. Etc.)
(1) (3) (4) referral) TB (10) facilities at the (13)
(8) clinic) (11) periphera
(9) l DOTS
facility
(12)
Ref: Column Ref: Ref: Ref: column 9 Ref: hosp. Ref: Ref: Ref: Ref: Ref:
Page 12 column hosp. 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
TOTA
L