Standard Operating Procedures for

Antiretroviral Drug Management

at Health Facilities
Guidelines for Forms

2nd Edition

Printed July 2006

DACA
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

This manual was made possible through support provided by the U.S. Agency for
International Development, under the terms of cooperative agreement number HRN-A-00-00-
00016-00. The opinions expressed herein are those of the author(s) and do not necessarily
reflect the views of the U.S. Agency for International Development.

About RPM Plus

RPM Plus works in more than 20 developing and transitional countries to provide technical
assistance to strengthen medicine and health commodity management systems. The program
offers technical guidance and assists in strategy development and program implementation
both in improving the availability of health commodities—pharmaceuticals, vaccines,
supplies, and basic medical equipment—of assured quality for maternal and child health,
HIV/AIDS, infectious diseases, and family planning and in promoting the appropriate use of
health commodities in the public and private sectors.

Recommended Citation

This manual may be reproduced if credit is given to RPM Plus. Please use the following
citation.

Rational Pharmaceutical Management Plus. 2006. Standard Operating Procedures for

Antiretroviral Drug Management at Health Facilities: Guidelines for Forms. Submitted to
the U.S. Agency for International Development by the Rational Pharmaceutical Management
Plus Program. Arlington, VA: Management Sciences for Health.

Rational Pharmaceutical Management Plus Rational Pharmaceutical Management Plus

Management Sciences for Health Management Sciences for Health
Bole K. Ketema, Kebele 02 4301 North Fairfax Drive, Suite 400
(Behind Friendship Shopping Complex on Arlington, VA 22203 USA
Bole Road) Telephone: 703-524-6575
Addis Ababa, Ethiopia Fax: 703-524-7898
P.O. Box 1157 code 1250 E-mail: [email protected]
Telephone: 251-11-662-07-81/91 Website: http://www.msh.org/rpmplus
Fax: 251-11-662-07-93

ii
 CONTENTS

ACRONYMS.............................................................................................................................1

INTRODUCTION .....................................................................................................................2

GENERAL INSTRUCTIONS ...................................................................................................3

ANTIRETROVIRAL DRUGS MANAGEMENT FLOWCHARTS ........................................5

Requesting and Receiving ARV Drugs .................................................................................5
Issuing ARV Drugs from the ARV Main Store.....................................................................6
Dispensing ARV Drugs from Outpatient and Inpatient Pharmacies .....................................7

FORMS AND MAIN PROCEDURES......................................................................................8

Ordering and Receiving Form (ARV/ORF-04) .....................................................................8
Antiretroviral Drugs and Patient Information Sheet (ARV/PIS-04)....................................12
ARV Drugs Dispensing Register (ARV/DDR-04) ..............................................................18
Monthly ARV Drugs Dispensing and Consumption Summary (ARV/DCS-04) ................22
Monthly ARV Drugs Pharmacy Activity Report (ARV/MAR-04).....................................25
Patient Tracking Chart (ARV/PTC-04) ...............................................................................30
Expiry Date Tracking Chart (ARV/ETC-04).......................................................................33
ARV Drugs Pharmacy Internal Monitoring Form (ARV/IMF-04) .....................................36
ARV Drugs Pharmacy Internal Monitoring Feedback Report (ARV/MFR-04) .................48

ADDITIONAL FORMS (Brief Explanations and Form Designs) ..........................................52

FORMS MODIFIED IN THIS EDITION …………………………………………………..62

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 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

ACKNOWLEDGMENTS
RPM Plus developed this manual to guide pharmacy personnel in providing ART services
and manage all types of data related to patients and ARV drug transactions.

This manual is written by Mr. Hailu Tadeg and reviewed by RPM Plus staff. Special thanks
are extended to Dr. Negussu Mekonnen, MSH/RPM Plus, Ethiopia, Mr. Gabriel Daniel,
MSH/RPM Plus, Arlington, Ms. Hella Witt, MSH/RPM Plus, Arlington and Hare Ram
Bhattarai, MSH/RPM Plus, Nepal.

iv
 ACRONYMS

3TC lamivudine
ADR adverse drug reaction
AIDS acquired immunodeficiency syndrome
ART antiretroviral therapy
ARV antiretroviral
DACA Drug Administration and Control Authority
DMIS drug management information system
HIV human immunodeficiency virus
INH isoniazid
I/O in- or outpatient
MoH Ministry of Health
NN non-naïve
OI opportunistic infection
PEP postexposure prophylaxis
PHARMID Pharmaceuticals and Medical Supplies Import and Distribution
Share Company
PMTCT prevention of mother-to-child transmission
RHB regional health bureau
RIR Receiving and Inspection Report
SOP standard operating procedure
TB tuberculosis
WHD Woreda Health Desk
ZDV zidovudine

1
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

INTRODUCTION

Pharmaceutical management at health facilities in Ethiopia is reportedly so poor that the

system in place does not allow for the effective and efficient monitoring that is required to
manage antiretroviral (ARV) drugs. The processes of selection, quantification, procurement
and ordering, distribution, and use are not uniform throughout the country’s health facilities.
The drug management information system operating at facility level is so minimal that the
information obtained is of little importance or support for decision-making purposes. Activity
reporting is rare and is usually not complete enough to provide the information required to
address pharmaceutical supply management problems.

Effective inventory management should help facilities avoid stock-outs and losses due to
unnecessary expiry, theft, and other problems, and ensure that the desired medicines are
available at all times in adequate quantities. A reliable supply of ARV drugs is critical for
two reasons: stock-outs could lead to dangerous consequences, and losses are unacceptable
because of the very nature of the medicines and their significant cost.

This level of management requires an effective and efficient system to monitor every step in
the process. Developing standard operating procedures (SOPs) for all the activities is an
important means of achieving this purpose. SOPs have already been developed; however,
training of pharmacy professionals on the formats, procedures, and management tools
included in the SOPs is a time-consuming undertaking. This manual is, therefore, meant to
help the pharmacy personnel who are expected to manage ARV drugs to become familiar
with the most important forms and procedures.

2
 GENERAL INSTRUCTIONS

Completing the Forms

• When entering information into all forms, write neatly and legibly.

• Deleting, erasing, or whiting out of entries is not allowed. If wrong entries are made,
cross out the words or phrases with one line and put your initials or signature (e.g.,
Outpatient pharmacy Inpatient pharmacy B.M.).

• While entering data, follow the rows strictly to avoid mix-ups of information.

• All information required in a form should be completed. Do not leave empty any space
allocated for you to record data.

• If a form is to be filled in by different individuals, complete your part and leave the other
parts for the assigned person to complete.

• After recording all the necessary data into a form, file it properly as described in the
manual.

• Make sure that confidential forms are kept in secured places under lock and key.

• Make sure that all forms are available in adequate quantities at your facility at all times.

• Write in a size that fits the provided space.

• Write all entries and reports in English (not in Amharic).

• Make sure that units of issues are consistent and entered correctly (tablets, packs, bottles,
etc.).

• All dates must be uniform. Use either the Ethiopian or Gregorian calendar. Be consistent
in writing dates (mm/dd/yy: 12/23/06, or dd/mm/yy: 23/12/06, or date name of month
and year: 23 Dec. 2006).

• Keep a calendar with both dates (Ethiopian and Gregorian) for reference.

• For expiry dates, use the date as printed by the manufacturer and insert the equivalent
date in the Ethiopian calendar in a bracket stating that it is in the Ethiopian calendar.

• Keep a Stock Card or Bin Card for forms as you do for medicines and supplies.

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 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Other Do’s and Don’ts

• Limit the number of persons responsible for ARV drugs in the pharmacy to not more than
two.

• Limit access of keys to antiretroviral therapy (ART) storage and to the filing cabinet to
the two persons above.

• Follow the manufacturer’s instructions in storing items that need refrigeration.

• Make sure that refrigerators are not overstuffed because the effectiveness of refrigerators
is dependent on air circulation.

• Do not keep food or drink in the refrigerator.

• Keep all opened liquid ARV drug preparations in the refrigerator, and discard
appropriately after the date stated as unusable.

• Make sure that ARV drugs as well as records and forms that are confidential are kept in
secure places under lock and key.

• Post instructions for patients on the purpose and use (e.g., counseling, confidential
dispensing) of booths.

• Instruct the patient to keep the doors of booths always closed from the inside.

• Do not allow more than one patient into a booth at a time.

4
 ANTIRETROVIRAL DRUGS MANAGEMENT FLOWCHARTS

Requesting and Receiving ARV Drugs

The pharmacy employee in charge of the main store prepares Ordering and Receiving
Form in consultation with the head of the pharmacy department by filling in quantities
needed in the “Items Ordered” section of the form and forwards it to the medical director for
approval signature and accompanying letter. The requisition form along with the
accompanying letter is sent to the supplier (e.g., Pharmaceuticals and Medical Supplies
Import and Distributor [PHARMID], the Ministry of Health [MoH], the regional health bureau
[RHB], the Woreda Health Desk [WHD]).

The supplier receives the Ordering and Receiving Form, fills in the “Items Supplied”
section of the form, and makes appropriate arrangements for delivery to the main store of
the health facility. The deliverer or collector (receiver) fills in the “Items Received” section of
the form and then receives the items. One copy of the Ordering and Receiving Form is left
with the supplier.

Pharmaceuticals arrive at the main store of the health facility accompanied by a completely
filled-out Ordering and Receiving Form and an invoice or delivery note or an Issuing
Voucher (Model 22 or other equivalent and legally approved forms) specifying the
contents.

The pharmacy employee in charge of the main store checks quantities received against the
Ordering and Receiving Form and invoice or delivery note or the Issuing Voucher (Model
22) and fills out the Receiving Voucher (Model 19 or other equivalent and legally approved
forms). Any discrepancies are recorded on Receiving Discrepancy Reporting Form and
sent to the supplier. The supplier makes all the necessary arrangements for replacing the
damaged stock.

The pharmacy employee in charge of the main store records receipt of ARV drugs on the
Bin Cards and Stock Cards, checks that the balances are correct, and stores the ARV
drugs at the main store under tightly secured conditions.

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Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Issuing ARV Drugs from the ARV Main Store

Outpatient Pharmacy Inpatient Pharmacy

Pharmacy employee in charge of the Pharmacy employee in charge of the

outpatient pharmacy completes an inpatient pharmacy completes an
Ordering and Receiving Form for the Ordering and Receiving Form for the
ARV drugs needed. ARV drugs needed.

The Main Store

The pharmacy employee in charge of the main store

issues the requested medicines, records the issues in
the “Items Supplied” section of the Ordering and
Receiving Form and Issuing Voucher (Model 22),
updates the Bin and Stock Cards and checks that the
balances are correct.

Outpatient Pharmacy Inpatient Pharmacy

The pharmacy employee in charge of the main The pharmacy employee in charge of the main
store endorses the Ordering and Receiving store endorses the Ordering and Receiving
Form and delivers the ARV drugs to the Form and delivers the ARV drugs to the
pharmacy employee in charge of the outpatient pharmacy staff member in charge of the
pharmacy. The outpatient employee checks inpatient pharmacy. The staff member checks
that quantities received are correct and fills in that quantities received are correct and fills in
the “Items Received” section of the Ordering the “Items Received” section of the Ordering
and Receiving Form, signs for the medicines and Receiving Form, signs for the medicines
on the Issuing Voucher (Model 22). One copy on the Issuing Voucher (Model 22). One copy
of the Ordering and Receiving Form is kept of the Ordering and Receiving Form is kept
at the main store and outpatient pharmacy. at the main store and inpatient pharmacy.

Outpatient Pharmacy Inpatient Pharmacy

The pharmacy employee in charge of the The pharmacy employee in charge of the
outpatient pharmacy records the receipts on inpatient pharmacy records the receipts on
Stock Movement Cards and checks that the Stock Movement Cards and checks that the
balances are correct. The employee secures balances are correct. The employee secures
the ARV drugs in the outpatient pharmacy the ARV drugs in the inpatient pharmacy store
store in a locked cabinet. in a locked cabinet.

6
 Antiretroviral Drugs Management Flowcharts

Dispensing ARV Drugs from Outpatient and Inpatient Pharmacies

Outpatients Inpatients

The prescriber issues a Prescription The nurse in charge brings the

Paper (VRA) which the patient or Prescription Paper (VRA) and the
patient’s representative brings to the Patient’s Card to the inpatient
outpatient pharmacy. pharmacy.

Outpatient Pharmacy Inpatient Pharmacy

The pharmacy employee in charge of The pharmacy employee in charge of

dispensing ARV drugs at the outpatient dispensing ARV drugs at the inpatient
pharmacy checks the eligibility of the pharmacy checks the eligibility of the
prescription, the regimen, dose, and time patient (i.e., whether he or she is a
of returning for refill with the patient’s ARV postexposure prophylaxis [PEP] or
Drugs and Patient Information Sheet. emergency case), the regimen, and dose.
The employee then endorses the The employee then endorses the
Prescription Paper, recording quantity to Prescription Paper, recording the quantity
be issued, date of dispensing, and dose to be issued, date of dispensing, and dose
dispensed. dispensed.

Outpatient Pharmacy Inpatient Pharmacy

The pharmacy employee who The pharmacy employee in charge of
dispenses ARV drugs at the outpatient dispensing ARV drugs at the inpatient
pharmacy fills in the ARV Drugs and pharmacy dispenses the prescribed
Patient Information Sheet, ARV medicines and records the issues in
Drugs Dispensing Register, and the ARV Drugs Dispensing Register
Stock Movement Card. for PEP or ARV Drugs Dispensing
Register for Emergency Supply, as
applicable, and on the Stock
Movement Card.

Outpatients Inpatients

The pharmacy employee in charge of The pharmacy employee in charge of

dispensing ARV drugs at the outpatient ARV drugs dispensing at the inpatient
pharmacy issues the ARV drugs to the pharmacy issues the ARV drugs to the
outpatient or the patient’s nurse who is responsible for collecting
representative, and counsels the the medication.
patient or representative on the
medication use.

7
 FORMS AND MAIN PROCEDURES

Ordering and Receiving Form (ARV/ORF-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

Ordering and receiving forms currently used by different health facilities are not uniform. In
the government health facilities under MoH, issuing and receiving are carried out using
Model 22 and Model 19, respectively, whereas other government health facilities that are not
under MoH (e.g., Armed Forces Hospital) use their own legally approved forms. Models,
although extensively used at different health facilities, are not designed for medicines and
hence they miss information important for pharmaceutical management purposes. All these
lead to non-uniform pharmaceutical practices at different health facilities. The Ordering and
Receiving Form is designed to enable all health facilities to use the same, standard
procedures when ordering and receiving ARV drugs. The models and other legally approved
forms shall be used in parallel to the newly developed form because they are the legally
accepted formats by the financial offices.

Definition

The Ordering and Receiving Form is a serially numbered triplicate form that is used for
ordering, supplying, and receiving ARV drugs.

Purpose

The main purposes of the Ordering and Receiving Form are—

• To order and receive ARV drugs from the main store within the health facilities, e.g.,
inpatient and outpatient pharmacy

• To order and receive medicines from suppliers outside the health facilities, e.g.,
Pharmaceuticals and Medical Supplies Import and Distribution
Share Company (PHARMID), Regional Health Bureau (RHB)

The form makes filling in the entries easier by preprinting the medicines so that the
requesting, supplying, and receiving parties will need to write only the figures. The other
advantage of the form is that the request, supply, and receipt information are all summarized
into one single sheet, providing at one glance an overview of what has happened at the
different parties involved. This organization also avoids unnecessary duplication of
information and, in addition, makes information easily accessible from a single form rather
than being spread over separate ordering, supplying, and receiving forms.

8
 Forms and Main Procedures

Who Fills Out the Form

The Ordering and Receiving Form is to be filled out by the requesting person who may be—

• The store manager, in the case of ordering from suppliers outside of the health
facilities

• The pharmacy employee in charge of inpatient and outpatient pharmacy, in the case of
ordering ARV drugs from the main store within the health facilities

When to Fill Out the Form

The Ordering and Receiving Form is to be filled out when the pharmacy employee in charge
needs to order a new supply of ARV drugs to replenish the stock. As currently envisioned,
the main store must place orders every month, but the frequency of ordering may change
when the health facilities have more stable patient numbers and are able to predict the
numbers of new patients with reasonable accuracy.

How to Fill Out the Form

The Ordering and Receiving Form has three main sections—Items Ordered, Items Supplied,
and Items Received. All these sections are to be filled out by different persons as indicated on
the form.

• The Items Ordered section is filled out by the requesting section that could be—

o The outpatient or inpatient pharmacy for transactions within the health facility

o The main pharmacy for transactions outside the health facility

• The Items Supplied section is filled out by the supplying section that could be—

o The main pharmacy for transactions within the health facilities

o The supplier such as PHARMID or RHB for transactions outside the health
facility

• The Items Received section is filled out by the receiving section that could be—

o The outpatient or inpatient pharmacy for receiving from the main store within the
health facility

o The main store for receiving from the supplier such as PHARMID or RHB

All individuals involved in the transactions should put their names and signatures under the
spaces reserved in the corresponding sections of the form.

The Delivery Mode refers to how the supply is delivered and hence it will be filled out as
either “delivered” if the supplies are to be delivered by the supplying party or “collected” if
the items are collected by the health facilities.

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 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

The Delivery Person is the person who was assigned to take the responsibility of
transporting the medicines from the supplier to the health facility for transactions outside the
health facilities or from the main store to the outpatient or inpatient pharmacy for transactions
within the health facilities.

How to File

The form is prepared in three copies, and these copies are filed by—

• The main store manager of the health facility

• The supplier for transactions outside the health facility or the receiver for transactions
within the health facility

• The accounting section

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 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Ordering and Receiving Form (ARV/ORF-04)

Name of the Health Institution: ____________________________________________

Ref. No.
Requesting Section: Supplying Section:
Date Ordered: Date Received:
Ser Items Ordered Items Supplied Items Received
No. To be Filled out by Requester To be Filled out by Supplier To be Filled out by Receiver
Description (Name, strength, Stock on Quantity Quantity Expiry Batch Unit Total Quantity Remark/Discrepancy
Unit
dosage form and pack size) Hand Ordered Supplied Date No. Cost Cost Received
1. D4T 30 mg of 56
2. D4T 40 mg of 56
3. ZDV 300 mg of 60
4. ZDV+3TC 450 mg of 60
5. 3TC 150 mg of 60
6. NVP 200 mg of 60
7. EFV 600 mg of 30
8. EFV 200 mg of 90
9. EFV 50 mg
10. EFV 100 mg
11. ZDV 100 mg of 100
12. ZDV 10 mg/ml of 200 ml
13. 3TC 10 mg/ml of 240 ml
14. NVP 10 mg/ml of 240 ml
15. ABC 300 mg/Tenofovir 300 mg
16. ddl 25 mg of 60
17. ddl 100 mg of 60
18. LOP/r 133/33 mg of 180
19. NFV 250 mg of 270
20.
Ordered by: Approved by: Supplied by: Received/inspected by:
Signature: Signature: Signature: Signature:
Date: Date: Date: Date:
Delivery mode: Delivery person: Signature:
Comments:

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 Forms and Main Procedures

Antiretroviral Drugs and Patient Information Sheet (ARV/PIS-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

Currently, Ethiopia does not have a tradition of keeping patient information in the dispensing
pharmacy at all health facilities. The importance of such information becomes evident when a
patient needs follow up on the particular pharmaceutical treatment but to date, pharmacists
have not been involved in following up treatment outcomes, development of adverse drug
reactions (ADRs), side effects or allergies, or in other issues related to the medications. The
only way that the patient could get support in such situations is if he or she goes back to the
prescribing physician because most patients are not aware that the pharmacist can help them.

The pharmacist can, however, assist both the patient and the physician in many aspects
related to medicines. Use of pharmacists in this role can reduce significantly the number of
unnecessary repeat visits to the physician for minor problems that can easily be handled by
the pharmacist. This allows the physician to concentrate on patients with complicated cases.
In addition, the patient saves time because he or she can get support from the pharmacist,
who is easily accessible. The input of the pharmacist could, however, be substantial if he or
she had access to basic information about the patient’s history. If such information is
recorded and filed at the dispensing pharmacy, the pharmacist can offer an appropriate and
informed recommendation about the treatment based on the basic data available about the
patient. The Antiretroviral Drugs and Patient Information Sheet is designed to make this
idea a reality by making key patient information available to the pharmacist at the dispensary
pharmacy. It is also used as a major source of data about medications and other related
information that can be used for management purposes.

Definition

The Antiretroviral Drugs and Patient Information Sheet is a single-copy form that is used to
record information about the HIV patient.

Purpose

The purpose of Antiretroviral Drugs and Patient Information Sheet is to serve as a database of
patients receiving ARV drugs. Data from these information sheets will be transferred to the
ARV Drugs Dispensing Register.

12
 Forms and Main Procedures

The information sheet contains sociodemographic, clinical, medications, and other related
information pertinent to the patient. Therefore—

• It is to be used as a major source of information about HIV patients at the dispensary.

• It will be helpful for the follow-up of ADRs, side effects, drug-drug and drug-disease
interactions, adherence, patterns of use for medicine or regimen, patterns of
resistance, and other related encounters.

• It is to be prepared for individual patients.

Who Fills Out the Form

The Antiretroviral Drugs and Patient Information Sheet is to be filled out by the pharmacy
employee dispensing the medications to the patient.

When to Fill Out the Form

The Antiretroviral Drugs and Patient Information Sheet should be filled out when the
medications are dispensed to the patient.

How to Fill Out the Form

The Antiretroviral Drugs and Patient Information Sheet is divided into three major sections,
each of which is used to record information about the patient, different clinical encounters,
and the medicines he or she is taking. These sections are—
• Patient information
• Clinical information
• Drug dispensing information

Patient Information

The information to be completed under this category can be obtained from the—
• Patient card (e.g., card number)
• Patient (e.g., address)
• Prescription (e.g., age, weight, patient source)

Clinical Information

This information is obtained primarily from the patient’s Treatment Card (e.g., concomitant
disease conditions and reasons for changing regimen), directly from the patient, or by simple
observations (e.g., ADR and side effects).

The dispenser should be able to use different techniques during conversation with the patient
to elicit accurate and relevant information from the patient about the other medicines he or
she is taking. For example, if the patient cannot name the other medicine or medicines he or
she is taking, the dispenser may have to trace the medicine by correlating it with the
symptoms for which the medicine was prescribed or by the color, size, dose, and other
characteristics of the medication to which the patient can easily relate to.

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 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Drug Dispensing Information

The information to be filled out in this category is obtained primarily from the Prescription
Paper but some information will be provided by the patient (e.g., prophylactic treatment,
taking other medications).

What to fill out in each column of the Antiretroviral Drugs and Patient Information Sheet
should be self-explanatory in most cases. Columns that may be less obvious are described
below.

Patient Information

• Date eligible—Refers to the date on which the patient was to start ART

• PEP—Refers to individuals given ARV drugs for the purpose of postexposure

prophylaxis (PEP)

• Emergency—Refers to patients who are supplied ARV drugs for a limited period (less
than a month) to avoid treatment interruptions. Examples include patients who have been
admitted to the health facility but forgot to bring their regular medications. The purpose is
to avoid interruption of doses until they get their regular medication from home or from
the outpatient pharmacy

• Transfer in—Refers to patients who have been referred from other health facilities and
decided to be served by this pharmacy

• PMTCT Plus—Refers to mothers and their close family members who are preferentially
eligible to receive ART in the course of prevention of mother-to-child transmission
(PMTCT) medicines (i.e., a mother who took ARV drugs to prevent transmission of HIV
to her child during delivery)

Clinical Information

• Previous Exposure to ARV Drugs—

o Naïve—Refers to patients that have not been exposed to ARV drugs before (i.e.,
patients that have no history of taking ARV drugs anywhere)

o Non-naïve (NN)—refers to patients that have already been on treatment for different
duration

o If NN, previous regimen—If the patient has already been taking ARV drugs
somewhere else (e.g., at Kenema or Red Cross pharmacies), the regimen that he or
she was on should be recorded here.

• Current Status—

o On active treatment—Refers to patients who are currently taking their ARV drugs on
a regular basis

o Transfer out—Refers to patients who have been referred to other health facilities

14
 Forms and Main Procedures

o Stopped by physician—Refers to patients who have stopped taking their regular ARV
drugs by physician’s order

o Lost for follow-up—Refers to patients who fail to collect their medicines within one
month after the next date of visit (who are late for more than one month)

• History of ADR or Side Effects—

o Date—When the ADR or side effect was observed

o Description—A short description of the ADR or side effect (e.g., Stevens-Johnson

syndrome, hepatitis, skin rash, vomiting)

• Concomitant Diseases—

o Date—The date on which the disease started (onset of the disease)

o Description—A short description of the disease the patient has contracted

concomitantly with the HIV (e.g., tuberculosis [TB], pneumonia, oral thrush)

• Reason for Change in Regimen or Other Remarks—

o Date—The date on which the regimen was changed

o Description—A short description of the reasons that the regimen has been changed
(e.g., toxicity, resistance, to improve adherence)

Drug Dispensing Information

• Reason for visit—The reason that the patient visited the pharmacy. There are three
possible reasons for the patient to visit the dispensary with an ART prescription.

o Start—Refers to patients who have been prescribed ARV drugs for the first time at
this pharmacy

o Refill—Refers to patients who are already on ART and visiting the dispensing
pharmacy to get their subsequent doses

o Switch—Refers to patients who are changing their previous regimen because of the
reasons justified by the physician

Notes:

1. All patients that are new to the health facility (even if they were on ART
somewhere else) should be considered as “Start”

2. All the three columns, including weight in kilograms, are to be completed

• In/outpatient (I/O) —Refers to whether the patient is an inpatient or outpatient at the time
the prescription is filled. If he or she is an inpatient, write I; if he or she is an outpatient,
write O in the column.

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 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

• Drug name—The abbreviated name of the medicine (e.g., zidovudine for ZDV or
lamivudine for 3TC)
• Strength/volume—For solid dosage forms, indicate the strength of the medicine (e.g., 300
mg); for liquid dosage forms indicate the amount of liquid in the container (e.g., 100 ml)
• Brand—The trade name of the medicine being dispensed (may be abbreviated)
• Quantity—The quantity of the medicine dispensed (number of tablets, capsules, or bottles
of liquid preparation)
• Months of supply—The number of months for which the dispensed medication will last
• INH prophylaxis—If a patient is taking isoniazid (INH) for TB prophylaxis—this column
is to be checked
• Co-trimoxazole prophylaxis—If a patient is taking co-trimoxazole for prophylactic
treatment, this column is to be checked
• Other drugs—If a patient is taking medicines other than ARV drugs for treatment, the
medicines are to be listed (If co-trimoxazole is taken for the treatment of an infection
rather than for prophylactic treatment, indicate that here)
• Date of next visit—The last date on which the patient should come back to the dispensing
pharmacy to collect the medications and beyond which the patient will run out of
medicine, if all doses were taken as prescribed; a patient who failed to come on this date
is said to have failed to adhere to the treatment

Note: The Date of Next Visit entry is different from the appointment date given to the
patient. The appointment date should be made two or three days earlier than the date of
the next visit which would be the day the patient takes his or her last medicine. If the
appointment date is determined by the clinician, the dispensing pharmacist should use the
same appointment date so that the patient can collect the medications on the same date he
or she visits the clinician. The dispensing pharmacist should, however, make sure that the
appointment is made two or three days ahead of the date of next visit. The idea is to help
the patient collect the medicines earlier before the doses are finished to avoid treatment
interruptions.

How to File

After the ARV Drugs and Patient Information Sheet is filled out, it should be filed in such a
way that it can be easily retrieved when the patient visits the dispensary next time. Therefore,
the organization used should file this information sheet in a way that allows it to be traced by
using a number or name that uniquely identifies a patient. The best possible means of
achieving this purpose is to use either the patient name or the patient card number. Although
using the card number is the better way to uniquely identify a patient, patients may forget to
bring their card numbers at the time of refill. For cross referencing, a record that contains a
patient name with the corresponding card number should also be prepared. The records
should be kept in a secure place to maintain confidentiality.

The Antiretroviral Drugs and Patient Information Sheet should therefore be filed in a filing
cabinet by the order of the patient’s card number, and the cabinet should always be locked
and be accessible only to the dispensing pharmacist.

16
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Antiretroviral Drugs and Patient Information Sheet (ARV/PIS-04)

Name of the Health Institution: ______________________________________

Patient Information Clinical Information
Card No.: ______________ Previous Exposure to ARVs: □ Naïve (N) □ Non-Naïve (NN) If NN, Previous Regimen: ______________________________
Name: _____________________________ Current status: □ On active treatment □ Transferred-out □ Stopped t/t by physician □ Lost for follow-up □ Deceased
Sex: □ Male □ Female Age: ………years History of ADR or Side Effects Concomitant Diseases Reason for change in regimen or other remarks
Date Eligible: ………….. Wt. on Start: ……. Kg
Date Description Date Description Date Description
Patient Source:
□ Inpatient □ Outpatient □ Transfer in
+
□ PEP □ PMTCT □ Emergency
Patient’s: Support Person’s:
Addres
s

Tel: Tel:

Drug Dispensing Information

Reaso Antiretroviral Drugs Dispensed
Prescriber

Cotrimox Prophylaxis
n for
In/Out Patient (I/O)

Months of Supply

Date of Next Visit

visit

INH Prophylaxis
Weight in Kg

Drug 1 Drug 2 Drug 3

Signature
Start
Refill
Switch

Initial

Presc. No.

Other Drugs
Date
Drug Name

Drug Name

Drug Name
Quantity
Strength/

Strength/

Strength/
Quantity

Quantity
Volume

Volume

Volume
Brand

Brand

Brand

17
 Forms and Main Procedures

ARV Drugs Dispensing Register (ARV/DDR-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

Recording the type and quantity of items issued to patients at the dispensing pharmacy is
significant for monitoring both pharmaceutical consumption and use at the dispensary. In the
system currently in place, a prescription registration book was meant to serve this purpose,
but in reality it was seldom used to record dispensed medications in many of the health
facilities. Furthermore, the information recorded in the prescription registration book cannot
satisfy fully the information requirements of a management information system for ARV
drugs. The ARV Drugs Dispensing Register was designed to allow efficient information
management for ARV medication consumption at facility level. The register needs to be
completed for every issue of ARV drugs at the dispensary.

Definition

The ARV Drugs Dispensing Register is a registry book that is used to record key patient
information and quantities of ARV drugs dispensed to these patients.

Purpose

The purpose of the ARV Drugs Dispensing Register is to summarize drug dispensing
information and key patient information relevant to ARV drug use in one sheet so that the
information can be easily retrieved and further processed. The information entered in the
ARV Drugs Dispensing Register is taken from the ARV Drugs and Patient Information Sheet
and shall be registered in an orderly fashion each time ARV drugs are issued at the
dispensary pharmacy.

Who Fills Out the Form

The ARV Drugs Dispensing Register is filled out by a pharmacy clerk, a pharmacy assistant,
a health assistant, or any other employee assigned by the health facility to carry out the
recording. The pharmacist in charge has to make sure that the person filling out the register
will maintain the confidentiality of patient data.

When to Fill Out the Form

The ARV Drugs Dispensing Register is preferably filled out immediately after dispensing the
medications. If there is shortage of personnel, filling out the ARV Drugs Dispensing Register
may be done at the end of the day or after working hours, but it must be filled out daily.

18
 Forms and Main Procedures

How to Fill Out the Form

All the information necessary to complete the ARV Drugs Dispensing Register is obtained
from the Antiretroviral Drugs and Patient Information Sheets, which are filled out during the
day and are collected; the information is copied to the ARV Drugs Dispensing Register
immediately after dispensing or at the end of the day, as appropriate.

The information to be filled out in the ARV Drugs Dispensing Register is quite obvious from
the titles of the columns. Only few columns are explained below:

• Refills collected on time—This information will help the dispenser identify a patient
who has not collected the refill medications on time. If the patient collects his or her
ARV drugs before or exactly on the date of next visit the respective cell will be
checked. The cell will be left empty if the refill medication is collected late.

• Reasons for Visit—The reason the patient visited your pharmacy. There are three
possible reasons for the patient to visit the dispensary with an ART prescription.

o Start—Refers to patients who are new to the health facility or pharmacy. But they
could be naïve or non-naïve.

ƒ Naïve—Refers to patients that have not been exposed to ARV drugs before
(i.e., patients that have no history of taking ARV drugs anywhere)

ƒ Non-naïve—Refers to patients that have already been on treatment for

different duration (e.g., patients who have been taking ARV drugs from
Kenema and Red Cross pharmacies)

o Refill—Refers to patients who are already on ART and visiting the dispensing
pharmacy to get their subsequent doses

o Switch—Refers to patients who are changing their previous regimen because of

the reasons justified by the physician

Notes:

1. All patients who are new to the health facility (even if they were on ART
somewhere else) should be considered as “Start.”

2. All the three columns, including weight in kilograms, are to be completed.

• Months of Supply Dispensed—The number of months that the dispensed ARV drugs
will last. Usually this will be one month but in some cases, when patients have
already been stabilized on the treatment, two or three months of supply might be
dispensed.

• Quantity Dispensed—In all the columns under the three groups of ARV drugs (i.e.,
first-line, pediatric, and second-line formulations), enter the quantity of medicines (in
tablets, capsules, or bottles of liquid preparation) dispensed to the patient.

19
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

• Patients Receiving—For planning purposes, knowing how many of the patients on

ART are taking prophylactic treatment, TB treatment, or medicines for opportunistic
infections (OIs) other than TB is of interest. If a patient is on any of the above
treatments, check the corresponding cell.

• Total—
o Count—The total count of entries under each column
o Sum—The sum of the entries under each column

Notes:

1. No data are to be filled under the shaded region.

2. For most columns, either the count or sum is to be filled in, but for the columns
under “Months of Supply Dispensed,” fill in both count and sum.

Reason—Entries under the column “Months of Supply Dispensed” are numbers (which may
be 1 or 2 or rarely 3 to indicate the number of months that the dispensed medication will last).
The types of information expected to be derived from this column are two—

• The total number of months that each regimen has been prescribed during that month
(the sum will give this information)

• The number of patients under each regimen for that month (the count will give this
information)

How to File

Since ARV Drugs Dispensing Register is prepared in the form of bound book, it is not
necessary to separate the completed sheets. Data should be summed up, however, at the end
of each page as well as at the end of the month. The register should be completed in an
orderly and chronological fashion, page by page. The monthly summary will be transferred
into the Monthly ARV Drugs Dispensing and Consumption Summary form at the end of each
month.

20
 Drugs for other OI’s
Receiving
Patients

TB treatment
Cotrimox Prophylaxis
INH Prophylaxis
line Drugs Dispensed
Quantity of Second-

NFV 250 mg
LOP/r 133/33 mg
ddl 100 mg
ddl 25 mg
ABC 300 mg /Tenofovir 300
mg
Formulations Dispensed

NVP 10 mg/ml of 240 ml

Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Quantity of Pediatric

3TC 10 mg/ml of 240 ml

ZDV 10 mg/ml of 200 ml
ZDV 100 mg of 100
EFV 100 mg
ARV Drugs Dispensing Register (ARV/DDR-04)

EFV 50 mg
EFV 200 mg
Quantity of First-line Adult Formulations

EFV 600 mg
NVP 200 mg
3TC 150 mg
Dispensed

ZDV+3TC 450 mg
ZDV 300 mg

21
D4T 40 mg
D4T 30 mg
Name of the Health Institution: ____________________________
Reasons for Months of Supply

Other
Dispensed

ZDV/ddI/LOPr
ZDV/3TC/EFV
ZDV/3TC/NVP
D4T/3TC/EFV
D4T/3TC/NVP
Switch
Refill
Visit

Non-Naive
Start
Naive
Refills Collected on Time
Weight above 60
PMTCT Plus
Inpatient
Adult > 12
Group
Age
Child 5-12 years
Child < 5 years
Male

Sex
Female

Count
Sum
Card Number
Date

Total
Ser. No.
 Forms and Main Procedures

Monthly ARV Drugs Dispensing and Consumption Summary (ARV/DCS-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

Experiences with the current system indicate that although the information recorded at the
pharmacy department is usually filed, it is not likely to be used by anybody for making
decisions about modifying systems or improving performances. Likewise, individuals
recording the information often are not aware of what to do with it. This lack of
understanding of its purpose undoubtedly will result in recording fatigue and lack of
motivation on the part of the recorder to fill out the forms completely and correctly.
Ultimately the data will no longer be useful to anyone and will produce no returns for all the
effort put into gathering it. Ineffective record-keeping is a waste of resources (time, money,
and expertise). Many benefits can be obtained, however, from data recorded on a form that
has been designed to accommodate relevant information to meet the desired needs. Therefore,
the Monthly ARV Drugs Dispensing and Consumption Summary was designed to be
identical to the ARV Drugs Dispensing Register but is completed monthly and is used to
summarize information that is important for decision making and reporting at the facility.

Definition

The Monthly ARV Drugs Dispensing and Consumption Summary, a single-copy form kept at
the outpatient pharmacy, is used as the main source of information for decision making and
reporting. The information is derived from the ARV Drugs Dispensing Register and provides
an overview of the development of pharmaceutical consumption and patient parameters over
time.

Purpose

The Monthly ARV Drugs Dispensing and Consumption Summary is meant to be used solely
for internal use by the pharmacy department. The purposes of this summary form are—

• To make available to the pharmacist an overview of summary data for the month in
different areas relevant to ARV drug management and use. When this information is
collected for several months, it can also be used to understand the trends and
developments over the months and even years. This understanding, in turn, will allow
forecasting and predictions to be more reasonable and will make quantification easier
and more reliable.

• To serve as an important source of information from which the data for the monthly
report can be extracted.

22
 Forms and Main Procedures

Who Fills Out the Form

The Monthly ARV Drugs Dispensing and Consumption Summary should be completed by
the pharmacy employee in charge of dispensing ARV drugs. He or she should take care not to
make mistakes while summing up entries.

When to Fill Out the Form

The Monthly ARV Drugs Dispensing and Consumption Summary is to be filled out at the
end of each month. Only sums or total counts are to be filled.

How to Fill Out the Form

The titles of the column in the Monthly ARV Drugs Dispensing and Consumption Summary
are identical to that of the ARV Drugs Dispensing Register, therefore the total counts or the
sums of each column are calculated and copied directly.

How to File

The Monthly ARV Drugs Dispensing and Consumption Summary is prepared as a bound
form printed on the back of the ARV Drugs Dispensing Register, and hence it is completed
page by page and filed along with the ARV Drugs Dispensing Register.

23
 Died
Total No of

Lost for Follow Up

Patients

Stopped by Physician
Transferred out
Received PEP
No of Patients

Drugs for other OI’s

Receiving

TB treatment
Cotrimox Prophylaxis
INH Prophylaxis
Second-line Drugs

NFV 250 mg of 270

Quantity of

Dispensed

LOP/r 133/33 mg of 180

ddl 100 mg of 60
ddl 25 mg of 60
Monthly ARV Drugs Dispensing and Consumption Summary (ARV/DCS-04)

ABC 300 mg /Tenofovir 300 mg

NVP 10 mg/ml of 240 ml
Quantity of Pediatric

3TC 10 mg/ml of 240 ml

Formulations
Dispensed

ZDV 10 mg/ml of 200 ml

ZDV 100 mg of 100
EFV 100 mg
EFV 50 mg
EFV 200 mg of 90
Quantity of First-line Adult Formulations

EFV 600 mg of 30
Forms and Main Procedures

NVP 200 mg of 60
3TC 150 mg of 60
Dispensed
Name of the Health Institution: ___________________________________

ZDV+3TC 450 mg of 60

24
ZDV 300 mg of 60
D4T 40 mg of 56
D4T 30 mg of 56
Other
Months of Supply

ZDV/ddI/LOP/r
Dispensed

ZDV/3TC/EFV
ZDV/3TC/NVP
D4T/3TC/EFV
D4T/3TC/NVP
Switch
Reasons for

Refill
Visit

Non-Naive
Start
Naive
Refills Collected on Time
Weight above 60
PMTCT Plus
Inpatients
Age Group
Adult > 18
Child 5-17 years
Child < 5 years
Male

Sex
Female
Total No. of New Patients
Total No. of Patients Served

Price

Price

Price

Price

Price

Price

Price

Price
Month
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Monthly ARV Drugs Pharmacy Activity Report (ARV/MAR-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

Undoubtedly, every department or section in a health facility reports to higher bodies in some
way about the activities it performs. Whatever the level and quality of the report may be, the
issue of what to do with the report is one of the most important issues to address. The
reporting body should receive some sort of feedback from the higher bodies. Otherwise,
writing reports merely for the purpose of filing them will benefit neither the authorities nor
the facilities.

To make the report useful, it should include important and relevant information that can help
program managers and higher authorities take appropriate measures and make good
decisions. Therefore, the Monthly ARV Drugs Pharmacy Activity Report is meant to
provide important information about the pharmacy activities related to ART and the same
information will be used by the concerned authority to make decisions, particularly those
related to the supply of ARV drugs and other issues that might have been indicated in the
report.

Definition

The Monthly ARV Drugs Pharmacy Activity Reporting Form is a two-page form that is used
for reporting activities related to the ART services carried out by the pharmacy department of
the health facility.

Purpose

The purpose of the Monthly ARV Drugs Pharmacy Activity Report is to report to the
concerned authorities the monthly ART activities of the pharmacy department in regard to the
extent of services provided, the characteristics of the patients served, the quantities and
values of ARV drugs consumed, the current stock status, the constraints faced, and so forth.

Who Fills Out the Form

The Monthly ARV Drugs Pharmacy Activity Report is to be filled out by head of the
pharmacy department by collecting the information from the relevant sections (i.e., from the
main pharmacy, outpatient and inpatient pharmacies).

25
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

When to Fill Out the Form

The Monthly ARV Drugs Pharmacy Activity Report is to be filled out at the end of each
month for reporting to the concerned authorities listed at the bottom right position on the first
page of the form.

How to Fill Out the Form

The titles of the columns in the Monthly ARV Drugs Pharmacy Activity Report are identical
to that of the Monthly ARV Drugs Dispensing and Consumption Summary. Therefore, the
first raw (total) is copied directly from that summary form. The rest of the information is
obtained from different sections. All pharmaceutical quantities are expressed in packs of
medicines or bottles for liquid preparations. Make sure that the correct pack size is indicated
in the reporting form and make appropriate adjustments, if necessary.

• PEP—Refers to individuals who have taken ARV drugs for PEP. These medicines are
given only at the inpatient pharmacy, so information regarding them is only obtained
from the inpatient pharmacy.

• Drugs Issued for—

o Emergency—Refers to medicines issued to patients who have been admitted to

the health facility and who have forgotten to bring their ARV drugs

o Return to supplier—Refers to the quantity of medicines that has been returned to

the supplier due to damage or expiry at the time of receipt or any other reasons

o Transfer to other facilities—Refers to the quantity of medicines that has been

transferred to other health facilities because they are overstocked at the facility or
they are short-dated and could not be consumed before they expire

• Total Number of Clients at the Facility:

o Transferred out to other facility Data to be collected from the dispensing
o Stopped treatment by physician pharmacies (primarily the outpatient
o Lost for follow up pharmacy)
o Died

o Quantity received last month

o Stock on hand
o Quantity on order Data to be collected
from the main store
o Quantity damaged or expired
o Quantity short dated
o Number of days out of stock last month

• Date audited—Refers to the date on which auditing or internal monitoring has been
made

• Problems encountered—Refers to the problems that have been encountered by the

pharmacy department during the previous month and that are negatively affecting the
accomplishment of the program

26
 Forms and Main Procedures

• Support needed—Refers to the support that the pharmacy department needs from the
concerned authority to improve the service

• Overall Remark/Comments—This is a space reserved for the pharmacist to record any

additional comments or remarks that are of importance for the ART program

How to File

A copy of the Monthly ARV Drugs Pharmacy Activity Report should be filed for every
month by head of the pharmacy department. One copy of the report should be sent to the
higher bodies listed on the bottom right position on the first page of the reporting form.

27
 Forms and Main Procedures

Monthly ARV Drugs Pharmacy Activity Report (ARV/MAR-04)

Name of the Health Institution: _______________________ Region: ___________ Reporting Month: _________ Date: _____
Quantity of Pediatric Quantity of Second-
Quantity of First-line Adult Formulations
Reasons for Months of Supply Formulations line Formulations No. of Patients
Sex Age Group Dispensed
Visit Dispensed Dispensed Dispensed Receiving

ABC 300 mg/Tenofovir 300

Refills Collected on time

NVP 10 mg/ml of 240 ml

ZDV 10 mg/ml of 200 ml

3TC 10 mg/ml of 240 ml

LOP/r 133/33 mg of 180

ZDV+3TC 450 mg of 60

Cotrimox. Prophylaxis

Drugs for other OIs

ZDV 100 mg of 100

NFV 250 mg of 270

NVP 200 mg of 60
ZDV 300 mg of 60

EFV 600 mg of 30

EFV 200 mg of 90
3TC 150 mg of 60
Weight above 60

ddl 100 mg of 60
Child 5-12 years

D4T 30 mg of 56

D4T 40 mg of 56

INH Prophylaxis
ddl 25 mg of 60
Child < 5 years

ZDV/3TC/NVP

ZDV/ddI/LOPr
D4T/3TC/NVP

ZDV/3TC/EFV
D4T/3TC/EFV

TB treatment
Start
PMTCT Plus

EFV 100 mg
EFV 50 mg
In-patients

Refill

Switch
Adult > 12
Female

Others
Male

mg
Non-Naive
Naive

Total:
Count
Total:
Sum
PEP Total No of PEP: ____ Drugs Issued for PEP
Drugs Issued for: Emergency
Return to Supplier
Transfer to Other Facilities
Quantity Received Last Month
Total # of clients at the facility: _______
Stock on Hand
Total # of patients (this month):
Transferred out to other facility: ______ Quantity on Order
Stopped t/t by physician: ______
Lost to follow up: ______ Quantity Damaged or Expired
Died: ______ Quantity Short Dated
(<6 months)
No of Days Out of Stock Last
Month
Name Signature Date Copies sent to:
Report prepared by: ___________________________ _______________ ___________ Medical Director
Report checked by: ___________________________ _______________ ___________ RHB/WHD
Report distributed by: ___________________________ _______________ ___________ RPM Plus

28
 Forms and Main Procedures

Cost of the Drugs Dispensed this Month Other ART Activities

S.N Item Description Price in Eth. Birr Date audited: __________

1 D4T 30 mg of 56
2 D4T 40 mg of 56 Number of adverse drug reactions reported during the month: _______
3 ZDV 300 mg of 60
Problems encountered: Yes No (If yes, list out the problems)
4 ZDV+3TC 450 mg of
60
5 3TC 150 mg of 60
6 NVP 200 mg of 60
7 EFV 600 mg of 30
8 EFV 200 mg of 90
9 EFV 50 mg
10 EFV 100 mg
11 ZDV 100 mg of 100
12 ZDV 10 mg/ml of 200
m
13 3TC 10 mg/ml of 240 Support needed: Yes No (If yes, explain the supports needed)
m
14 NVP 10 mg/ml of 240
ml
15 ABC 300
mg/Tenofovir 300 mg
16 ddl 25 mg of 60
17 ddl 100 mg of 60
18 LOP/r 133/33 mg of
180
19 NFV 250 mg of 270
20
21
Overall Remark/Comments:

29
 Forms and Main Procedures

Patient Tracking Chart (ARV/PTC-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

The success of ART depends heavily on the level of patient adherence to the treatment
schedule. Noncompliance to treatment leads to a significant level of treatment failure. One of
the biggest challenges of ART is, therefore, patient adherence—a challenge that pharmacists
can address by helping patients adhere to their treatment. The pharmacist also plays a major
role in advising prescribing physicians on selecting a regimen that might specifically match
the behavior or daily routines of a particular patient so that he or she will be more likely to
take medications regularly.

Despite the pharmacist’s best efforts, however, patients might still fail to comply with their
treatments. The pharmacist should have some means of identifying this noncompliant group.
Identification is not an easy task, of course, because the pharmacist has no assurance that a
patient is taking the medicines properly at home, even if he or she is collecting them on time
from the dispensing pharmacy. The pharmacist can be sure, however, that the patient is not
adhering to the treatment if he or she fails to collect the medications for the next supply on
time. Tracing these patients in a timely fashion, therefore, is necessary so they do not miss
prescribed doses.

The Patient Tracking Chart is designed to help the pharmacist trace patients who fail to
collect their medicines on time. The pharmacist, along with the ART team, can then look for
ways to contact those patients so that they will continue the treatment.

Definition

Patient Tracking Chart is a single-copy chart that is used to follow up with patients to
determine if they are keeping their appointment dates.

Purpose

The purpose of the Patient Tracking Chart is to monitor adherence to ART. If patients are
collecting their medications exactly on the appointment date, the dispenser may conclude that
they are probably adhering to their treatment schedules—although collecting medicines is not
an absolute indicator or evidence that patients are taking individual doses regularly and
appropriately. The failure of patients to collect their medications on the date of next visit is an
absolute indicator that they are missing doses (i.e., they are not adhering to the treatment).
Therefore, the pharmacist, along with the ART team members, should try to trace the patient
so that he or she can receive additional adherence counseling or other support required to
improve adherence.

30
 Forms and Main Procedures

The pharmacist should label the non-adherent group of patients in some way to be able to link
treatment outcomes with the history of their record on adherence or to be able to support
them or design a method that might help them improve adherence when they come for their
next supply. Thus the labels used are non-adhering, lost for follow-up, or died. The
operational definition for these terminologies is described as follows—

• Non-adhering—Refers to patients who failed to collect their medicines until the date
of next visit. A patient who was late even by one day is labeled as “Non-adhering.”

• Lost for follow-up—Refers to patients who fail to collect their medicines within one
month after the next date of visit (who are late for more than one month)

• Died—Refers to patients who were reported to have died

Who Fills Out the Form

The Patient Tracking Chart should be filled out by the dispensing pharmacist.

When to Fill Out the Form

The Patient Tracking Chart should be filled out immediately after dispensing.

How to Fill Out the Form

Immediately after dispensing, the dispenser should fill in the card number of the patient in the
column that corresponds to the date of next visit. The card numbers of all patients are then
recorded in a similar fashion. Every morning the dispenser will look at the Patient Tracking
Chart and take out the cards of all patients who are expected to visit the pharmacy on that
date. If any patient fails to come on that date, the dispenser should find a means for tracing
the patient in collaboration with other ART team members.

How to File

The Patient Tracking Chart is to be filed in such a way that it is accessible to the dispensers.
The information will not be reported. Rather it will be used only by the dispensers to follow
up HIV patients with regard to their behavior in collecting their medicines on time.

31
 Forms and Main Procedures

Patient Tracking Chart (ARV/PTC-04)

Name of the Health Facility: ____________________ Year: ___________

Month: _______________
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Remark

Month: _______________
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Remark

32
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Expiry Date Tracking Chart (ARV/ETC-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

The ultimate goal of appropriate pharmaceutical management is to be able to make all

essential medicines available at the health facility at all times in adequate quantities. More
important, a good management system avoids unnecessary wastage of medicines for any
reason. One of the major reasons that medicines are wasted is that they may have expired
without anyone noticing that the shelf-life date was approaching. Failure to notice
approaching expiry dates might lead to the loss of a significant amount of resources
(particularly money), especially in resource-limited countries. This type of loss is not
acceptable for pharmaceuticals such as ARV drugs, which are very expensive. To avoid such
unnecessary wastage, the facility must track the expiry dates of ARV drugs closely and
regularly. Expiry dates can be monitored using simple, easy techniques that enable the store
manager to trace the medicines that will expire within a specified period, so that he or she can
take appropriate action on the short-dated products before they become unusable. Doing so
will result in huge savings. The Expiry Date Tracking Chart is designed to serve this
purpose, and the procedures for using it are described below.

Definition

The Expiry Date Tracking Chart is a single-copy sheet of paper designed for monitoring the
expiry date of ARV drugs so that the pharmacist can plan appropriate actions to minimize
losses due to expiry.

Purpose

The purpose of the Expiry Date Tracking Chart is to track the expiry dates of ARV drugs.
The pharmacist will alert the concerned authority when the medicines and supplies should be
removed from the stock for exchange or destruction. The chart can be used for other
pharmaceuticals, too. When the medicines cannot be returned for exchange, the chart alerts
staff to remove expired stock so that it is not issued in error.

Who Fills Out the Form

The Expiry Date Tracking Chart is to be filled out by the store manager.

When to Fill Out the Form

The Expiry Date Tracking Chart should be filled out immediately after receiving the items
from the supplier.

33
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

How to Fill Out the Form

• Yellow and red stickers are used to mark the corresponding months.

o Red stickers are used to mark the actual month when each batch or lot of medicines
will expire.

o Yellow stickers are used to alert the store manager when to report to the concerned
authority that the supplies should be ready for exchange (if he or she anticipates that
they will not be consumed before the date of expiry).

• Stock on hand at the end of the month can be written in cells under the appropriate
months to figure the quantity on hand at that particular time.

• Each product has space to list three different batches or lots of medicines.

o If you have more than three batches or lots, record the three that expire first.

• The yellow sticker marks the expiry warning date; the red sticker marks the month when
the medicine expires.

• Put the yellow sticker in the grid that corresponds to the date six months before the expiry
date; put the red sticker in the grid that corresponds exactly to the date on which the
product expires.

• For the three months before the yellow warning dot, enter the current stock level of that
batch or lot in the relevant grid.

o The stock levels also show the rate of use and determine how much, if any, stock
should be returned or prepared for exchange.

• Remove the red dot only after the expired stock has been destroyed or removed from
stock.

• When the batch or lot expires or is used up, erase the entry and replace it with the next
batch to expire.

• When medicines or supplies are received, enter the new batch or lot number and expiry
date on the chart.

• If a medicine expires after the three years covered in the chart, record the medicine in the
chart, but do not include stickers. When updating the chart at the beginning of the new
year, if the medicine is still in stock and expires within the three years, add the stickers
accordingly.

• To reduce the number of entries, make two separate charts: one for liquid (e.g., syrups)
and one for solid (e.g., tablets or capsules) dosage forms.

How to File

The chart is to be hung on the wall for easy reference.

34
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Expiry Date Tracking Chart (ARV/ETC-04)

Drug Name Batch No

Year: 2005 Year: 2006
J F M A M J J A S O N D J F M A M J J A S O N D
Nevirapine 200 mg tablet AXIP/2022 12 8 5
GSK8/1114
Nevirapine 50 mg/5 ml susp. AX66/2506 40 24 15

35
 Forms and Main Procedures

ARV Drugs Pharmacy Internal Monitoring Form (ARV/IMF-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form
How to Fill Out the Form
How to File

Introduction

To check whether any program is running as smoothly as planned, auditing or monitoring the
activities is important, because it will allow early detection of problems and deficiencies that
are affecting or will affect the program negatively, and will ensure that appropriate corrective
measures are taken. In addition, using selective indicators for monitoring will help to improve
performances and possibly speed up the process by identifying and modifying specific tasks.
Current experience indicates that auditing is not carried out regularly. Even if it is done, its
goal is often not to improve performance, and it is unlikely to be used for taking corrective
measures on deficiencies. The ARV Drugs Pharmacy Internal Monitoring Form is
designed to serve as an internal audit tool for monthly monitoring of pharmacy activities
within the ART program. The results of this internal monitoring will be used by the hospital
management team and other concerned authorities to address the problem areas and
deficiencies observed.

Definition

The ARV Drugs Pharmacy Internal Monitoring Form is, in a sense, an auditing form that is
used for monitoring the activities of the pharmacy department with in the ART program using
different indicators.

Purpose

The purpose of the ARV Drugs Pharmacy Internal Monitoring Form is to monitor the overall
pharmacy activities as related to ARV management in terms of appropriate ordering,
handling, distribution, use, recording, and reporting. It enables responsible bodies to take
corrective measures on issues that might affect the proper running of the ART program.

Who Fills Out the Form

The ARV Drugs Pharmacy Internal Monitoring Form is to be filled out by a committee
assigned by the health facility. The committee members should all be elected from among the
ART team.

When to Fill Out the Form

The ARV Drugs Pharmacy Internal Monitoring Form is to be filled out monthly.

36
 Forms and Main Procedures

How to Fill Out the Form

The procedures for completing ARV Drugs Pharmacy Internal Monitoring Form are obvious
and the values for all indicators should be filled in.

How to File

This form is to be filed by the internal monitoring committee so that it can be used again for
the next month’s monitoring and that problem areas can be followed up easily.

37
 Forms and Main Procedures

ARV Drugs Pharmacy Internal Monitoring Form (ART/IMF-04)

(Internal monitoring will be carried out by the audit committee every month. The results of the internal monitoring will then be shared
with the chief pharmacist and other pharmacy personnel so that appropriate corrective measures are taken to improve problem areas).

Name of the Health Institution: ______________________________

Date: Month: Date: Month:
Ser Procedure Result Remark Advice Result Remark Advice
Adherence to Standard Prescribing and Dispensing Guidelines
a. Pick 5 prescriptions at random Total Dispensed:
dispensed in the month and write
Eligibility of Clients

as Total Dispensed.
b. Examine all the above Total Eligible:
prescriptions and count those
which are dispensed to eligible
clients and write as Total Eligible.
c. (a) and (b) should match. If not,
write the reasons in the remark
column and instructions, if any, in
1.

the advice column.

a. Pick 5 prescriptions at random Total Dispensed:

dispensed in the month and write
as Total Dispensed.
b. Examine all the above Total Authorized:
Authorization of

prescriptions, count those which

Prescriptions

bear authorized signatures, and

write as Total Authorized.
c. (a) and (b) should match. If not,
write the reasons in the remark
column and instructions, if any, in
2.

the advice column.

38
 Forms and Main Procedures

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Pick 5 refill prescriptions at Total Dispensed:
Patient Adherence to Treatment

random dispensed in the month

and write as Total Dispensed.
b. Examine the corresponding ARV Total Correct:
Drugs and Patient Information
Sheet for all prescriptions, count
those into which the information is
correctly transferred from the
prescriptions, and write as Total
Correct.
c. (a) and (b) should match. If not,
write the reasons in the remark
column and instructions, if any, in
3.

the advice column.

a. Pick 5 prescriptions at random Total Dispensed:

Completeness of Prescription Writing

dispensed in the month and write

as Total Dispensed.
b. Examine the prescription to see if Total Complete:
it contains complete information
including patient name, weight,
date, prescriber’s name and
address, drug name, strength,
dose, quantity, and frequency of
administration, and write as Total
Complete.
c. (b) should be complete for all
prescriptions. If not, write the
information missing in the remark
column and instructions, if any, in
4.

the advice column.

39
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Select 5 ARV Drugs and Patient Total Recorded:
Information Sheets recorded in the
Recording in the ARV/PIS-

month and write as Total

Recorded. Total Correct:
b. Examine and check for correct
recording of information on the
sheet and write as Total Correct.
c. (b) should be correct for all ARV
Drugs and Patient Information
Sheet. If not, write the information
04

missing or wrongly recorded in the

remark column and instructions, if
5.

any, in the advice column.

a. Select 5 ARV Drugs and Patient Total Recorded:

Information Sheets recorded in the
ARV/PIS-04 to ARV/DDR-04
Transfer of Information from

month and write as Total

Recorded. Total Correctly
b. Examine and check for correct Transferred:
transfer of information into ARV
Drugs Dispensing Register and
write as Total Correctly
Transferred.
c. (a) and (b) should match. If not,
write the information that is
wrongly transferred in the remark
column and instructions, if any, in
6.

the advice column.

40
 Forms and Main Procedures

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Select 1 regimen and 3 drugs Total Dispensed:
Recording in the ARV/DDR-04

dispensed in the month and write

as Total Dispensed.
b. Examine the ARV Drugs Total Correct:
Dispensing Register to see if
quantities dispensed are correctly
added up for the month and write
the number of regimens and drugs
added up correctly as Total
Correct.
c. (a) and (b) should match. If not,
write the reasons in the remark
column and instructions, if any, in
7.

the advice column.

a. Select 5 columns of the ARV Total Examined:

Drugs Dispensing Register that
show a summary figure at the end
Transfer of Information from

of the month and write as Total Total Correct:

ARV/DDR to ARV/MCS

Examined.
b. Check the number of entries that
are correctly transferred into the
Monthly ARV Drugs Dispensing
and Consumption Summary and
write as Total Correct.
c. (a) and (b) should match. If not,
write the reasons in the remark
column and instructions, if any, in
the advice column.
8.

41
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
Inventory Management in the main and Outpatient Pharmacy Stores
a. Pick 3 bin cards from the main Drug:
store at random and write the Bin Card
current balance as Bin Card Balance:
Balance. Stock Count:
b. Count the quantity of
Accuracy of Bin Card Balances

corresponding drugs and write the Drug:

count stock. Bin Card
c. (a) and (b) should match. If not, Balance:
find out if the discrepancies are Stock Count:
accounted for, state the reasons in
the remark column, and write Drug:
instructions, if any, in the advice Bin Card
column. Balance:
d. If the current stock of a drug is Count Stock:
zero (0), take this as an out of
stock situation, find out why this
happened, and note in the remark
9.

column.

a. Pick 3 bin cards from the main Bin Stock:

store at random and write the Current Stock:
10. Stock Count Discrepancy in the

current stock as Bin Stock.

b. Check the quantity recorded in the
Ordering and Receiving Form and Bin Stock:
write it as Received Stock. Current Stock:
Subtract quantity issued (found in
the bin card) from the Received
Stock and write as Current Stock. Bin Stock:
c. (a) and (b) should match. If not, Current Stock:
Bin Card

find out if the discrepancies are

accounted for, state the reasons in
the remark column, and write
instructions, if any, in the advice
column.

42
 Forms and Main Procedures

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Pick 3 stock cards from the main Stock Card
11. Agreement of Records in the

store at random. Look over the Stock:

balance and write as Stock Card Bin Card Stock:
Stock.
Bin and Stock Cards

b. Pick the corresponding bin cards Stock Card

and write the quantity as Bin Card Stock:
Stock. Bin Card Stock:
c. (a) and (b) should match for all
stock cards. If not, find out if the Stock Card
discrepancies are accounted for, Stock:
state the reasons in the remark Bin Card Stock:
column, and write instructions, if
any, in the advice column.

a. Select 5 ARV drugs stored at the Total Stored:

12. Adherence to Correct

main store at random and write as

Total Stored.
Arrangement of

b. Check if the drugs are arranged Total FEFO:

according to FEFO technique and
write it as Total FEFO.
c. (a) and (b) should match. If not,
Stock

state the reasons in the remark

column and write instructions, if
any, in the advice column.

43
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Select 5 ARV drugs stored at the Total Stored:
main store at random and write as
13. Adherence to Expiry

Total Stored.
b. Check if the Expiry Date Total Correct
Date Monitoring

Recording Chart indicates the Expiry:

Procedures

correct expiry of the lot and write

as Total Correct Expiry.
c. (a) and (b) should match. If not,
state the reasons in the remark
column and write instructions, if
any, in the advice column.

a. Pick 3 stock movement cards from Current Stock:

the outpatient pharmacy store at Stock Count:
14. Stock Count Discrepancy in
the Stock Movement Card

random and write as Current

Stock. Current Stock:
b. Count the quantity of Stock Count:
corresponding drugs and write as
Stock Count. Current Stock:
c. (a) and (b) should match. If not, Stock Count:
find out if the discrepancies are
accounted for, state the reasons in
the remark column, and write
instructions, if any, in the advice
column.

44
 Forms and Main Procedures

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Pick 3 bin cards from the main Bulk Bin Stock:
15. Agreement of Records in the Bin and

store at random and note the date, Phar Bin Stock:

name of the drug, and quantity
issued to the outpatient pharmacy Bulk Bin Stock:
store. Phar Bin Stock:
b. Select the stock movement cards
Stock Movement Cards

from the outpatient pharmacy Bulk Bin Stock:

store for the drugs listed in (a) and Phar Bin Stock:
verify if the entries match with the
quantities listed in (a).
c. (a) and (b) should match. If not,
find out if the discrepancies are
accounted for, state the reasons in
the remark column, and write
instructions, if any, in the advice
column.

Temperature Control
a. Select 3 days randomly from the
Completed
Log
Acceptable
month. Check the temperature log Day To
of the main store and see if the log
16. To Monitoring in the Main Store

was completed twice for each of

the days selected. If yes, put √
against each of the day in the 1
column Log Completed.
b. If a day is checked, find out if the 2
temperature was within the
acceptable limit. If yes, put 3
another √ in the column To
Acceptable.
c. All days should have √√. If not,
discuss, find out the reasons, and
list instructions, if any, in the
advice column.

45
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Select 3 days randomly from the

Completed
Log
Acceptable
To
17. To Monitoring in the Outpatient

month. Check the temperature log Day

of the outpatient pharmacy and see
if the log was completed twice for
each of the days selected. If yes,
put √ against each of the days. 1
b. If a day is checked, find out if the
temperature was within the 2
acceptable limit. If yes, put
Pharmacy

another √. 3
c. All days should have √√. If not,
discuss, find out the reasons, and
list instructions, if any, in the
advice column.

a. Select 3 days randomly from the

Completed
Log
Acceptable
To
18. To Monitoring of the Refrigerator

month. Check the temperature log Day

of the main store refrigerator and
see if the log was completed once
for each of the days selected. If
yes, put √ against each of the days. 1
b. If a day is checked, find out if the
at the Main Store

temperature was within the 2

acceptable limit. If yes, put
another √. 3
c. All days should have √√. If not,
discuss, find out the reasons, and
list instructions, if any, in the
advice column.

46
 Forms and Main Procedures

Date: Month: Date: Month:

Ser Procedure Result Remark Advice Result Remark Advice
a. Select 3 days randomly from the Day

Completed
Log
Acceptable
To
month. Check the temperature log
19. To Monitoring of the Refrigerator

of the outpatient pharmacy

refrigerator and see if the log was
at the Outpatient Pharmacy

completed once for each of the

days selected. If yes, put √ against 1
each of the day.
b. If a day is checked, find out if the 2
temperature was within the
acceptable limit. If yes, put 3
another √.
c. All days should have √√. If not,
discuss, find out the reasons, and
list instructions, if any, in the
advice column.

47
 Forms and Main Procedures

ARV Drugs Pharmacy Internal Monitoring Feedback Report (ARV/MFR-04)

Introduction
Definition
Purpose
Who Fills Out the Form
When to Fill Out the Form Is Filled Out
How to Fill Out the Form
How to File

Introduction

As can be seen from the number of pages of the ARV Drugs Pharmacy Internal
Monitoring Form, the information will not be summarized, so the concerned authorities will
need to go through all of its contents to find problem areas. Program managers are unlikely to
make this tedious search, but if they do not, the purpose of internal monitoring will be lost.
Therefore the internal monitoring committee should be able to summarize the key
deficiencies and problem areas that need the attention of higher authorities. The summary of
the findings of the internal monitoring will then be presented at a meeting with the program
managers so that remedial measures will be taken by these higher authorities. The ARV
Drugs Pharmacy Internal Monitoring Feedback Report is meant to achieve this goal (i.e.,
the key findings that need action are summarized into this form for presentation at the
meeting).

Definition

The ARV Drugs Pharmacy Internal Monitoring Feedback Report is a single-copy form that is
designed to be used for summarizing the key findings obtained from the internal monitoring.

Purpose

The purpose of the ARV Drugs Pharmacy Internal Monitoring Feedback Report is to enable
the monitoring committee to summarize issues of importance in one form and present it to the
concerned authorities so that appropriate decisions can be made

Who Fills Out the Form

The ARV Drugs Pharmacy Internal Monitoring Feedback Report is to be filled out by the
monitoring committee by picking the key findings from the internal monitoring form.

When to Fill Out the Form

The ARV Drugs Pharmacy Internal Monitoring Feedback Report is to be filled out
immediately after completing the internal monitoring activities.

How to Fill Out the Form

Key findings from the internal monitoring are summarized in this form.

48
 Forms and Main Procedures

How to File

The ARV Drugs Pharmacy Internal Monitoring Feedback Report should be filed in the same
manner that the ARV Drugs Pharmacy Internal Monitoring Form is filed.

49
 Forms and Main Procedures

ARV Drugs Pharmacy Internal Monitoring Feedback Report (ARV/MFR-04)

(This report will be presented by the audit committee in a meeting with the Medical Director and Chief Pharmacist.
This document will be retained by the audit committee with a copy provided to the Medical Director and Chief Pharmacist)

Name of the Health Institution: ____________________________

Approved by: Signature Date Approved by: Signature Date
1. Medical Director ___________ ______ 1. Medical Director ___________ ______
Procedure
2. Chief Pharmacist ___________ ______ 2. Chief Pharmacist ___________ ______
3. Audit Committee Chair ___________ ______ Month…… 3. Audit Committee Chair ___________ ______ Month…..
Adherence to Prescribing and Dispensing Guidelines
1. List of improvements from last
audit

2. What was done to improve?

3. New issues this month

4. Issues still pending with reasons

Stock in ARV Bulk and Outpatient Pharmacy Stores

1. What was done to improve

2. New issues this month

3. List of improvements from last

audit

4. Issues still pending with reasons

50
 Forms and Main Procedures

Approved by: Signature Date Approved by: Signature Date

1. Medical Director ___________ ______ 1. Medical Director ___________ ______
Procedure
2. Chief Pharmacist ___________ ______ 2. Chief Pharmacist ___________ ______
3. Audit Committee Chair ___________ ______ Month…… 3. Audit Committee Chair ___________ ______ Month…..
Temperature Control

1. What was done to improve?

2. New issues this month

3. List of improvements from last

audit

4. Issues still pending with reasons

51
 ADDITIONAL FORMS (BRIEF EXPLANATIONS AND FORM DESIGNS)

Receiving Discrepancy Reporting Form (ARV/RDR-04)

• Replaces Receiving and Inspection Report (RIR) currently in place
• Used only in cases where discrepancies are encountered during receiving

Bin Card— At the main store; currently in use

Stock Card— At the main store; currently in use

Stock Movement Card— At the dispensary; new

• Serves the same purpose as Bin Cards with additional useful information
• Is to be completed in single units at the end of each day

ARV Drug Dispensing Register for PEP

• Used to record medicines issued for the purpose of PEP
• Expected to be placed in the inpatient pharmacy that provides 24-hour service

ARV Drug Dispensing Register for Emergency Supply

• Used to record medicines issued as emergency supplies
• Expected to be placed in the inpatient pharmacy that provides 24-hour service.

ARV Drugs Expiry and Damage Inventory Sheet

• Used for recording expired and damaged items until they are disposed of
• Unusable items will be deleted from Bin and Stock Cards and temporarily recorded into
this sheet.

Temperature Recording Chart

• Used for twice daily temperature monitoring at the main store, outpatient dispensary, and
refrigerators

Prescription Paper
• The only legal prescription paper designed and approved by Drug Administration and
Control Authority (DACA) for prescribing ARV drugs
• It is serially numbered and to be audited like the medicine itself

52
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Receiving Discrepancy Reporting Form (ARV/RDR-04)

Name of the Health Institution: _________________________________
Issuing Voucher No.: ______________ Reported by: _______________
Date of inspection/Receipt: _________________ Reported to: ________________

Ser Description of Items Unit Batch No Expiry date Manufacturer Quantity Remark
No (Name, Strength, Pack Size and dosage form) or Country of Expected Actual Discrepancy
origin Received

Name Signature Date

Received By: ______________________ ______________________ _________________
Delivered By: ______________________ ______________________ _________________
Witnessed By: ______________________ ______________________ _________________

53
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

Bin Card

Name of the Health Institution: _________________________

Name, Strength, and Dosage Form of the Drug: __________________________________________________________
Unit of Issue: ____________

Date Document No. Received from or Quantity Batch Expiry Remark

(Receiving or Issued to Number Date
Issuing)
Received Issued Balance

54
 Additional Forms (Brief Explanations and Form Designs)

Stock Card
Maximum Stock Level: ________
Reorder Level: _______________
Name of the Health Institution: ________________________ Minimum Stock Level: _________
Product Name: ____________________________Strength: ________ Dosage Form: ____________
AVG. Monthly Consumption: ____
Unit of Issue and Pack Size: _______________________
Date Voucher No. Received from or Quantity Unit Price Expiry Date Remarks
(receiving or Issued to
issuing) Received Issued Balance

Total Monthly Consumptions

Total
Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Used
Total Expired
200__
200__
200__

55
 Additional Forms (Brief Explanations and Form Designs)

Stock Movement Card (ARV/SMC-04)

Name of the Health Institution: _____________________________________ Maximum Stock Level _____
Department: ___________________________ Minimum Stock Level _____
Description (Name, strength, and dosage form of the drug): __________________________________________
Unit: _________________________

Date Document Source or Quantity Physical Discrep- Expiry Remark

No.(receiving Destination Count ancy Date
or issuing Received Issued Balance
form)

56
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

ARV Drugs Dispensing Register For Post Exposure Prophylaxis (ARV/PEP-04)

This form is to be used at the inpatient pharmacy only for recording ARV drugs issued for the purpose of Post Exposure Prophylaxis.

Name of the Health Institution: _______________________________________

Profile of Exposed Individual Source of Exposure Prescribing Drugs Dispensed

Physician
Date Name Age Sex Profession Department Needle Mucosa Others Initial Reg. Description (Name, Qty Signature
Stick No. strength, dosage form)

57
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

ARV Drugs Dispensing Register for Emergency Supply (ARV/DES-04)

This form is used for recording short-term supplies of ARV drugs that are dispensed to inpatients admitted to the hospital and who have forgotten to bring their regular ARV drugs

Name of the Health Institution: _______________________________

Prescribing
Date Patient Name Card No. Drugs Dispensed Physician Reasons for Supply Signature
Description (Name, strength, dosage form) Qty Initial Reg. No.

58
 Additional Forms (Brief Explanations and Form Designs)

ARV Drugs Expiry and Damage Inventory Sheet (ARV/EDI-04)

Name of the Health Institution: _________________________

Date Description of the Item Date Receiving Received Unit Quantity Transferred Price Remark Initial
(Name, strength, pack size, and dosage Received Voucher From Expired Damaged Others Unit Total
form) No. (Model Price Price
19)

59
 Additional Forms (Brief Explanations and Form Designs)

Temperature Recording Chart (ARV/TRC-04)

Month/Year: ____________ Location: _______________

`
Morning Initial Afternoon Initial
Date
Time Recorded Time Recorded
Temp. (0C) Temp. (0C)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

60
 Additional Forms (Brief Explanations and Form Designs)

PRESCRIPTION PAPER O2 VRA No 000000

Name of the Health Institution ___________________________________
Address: Reg. ____________ Town ________ Tel ______ P.O. Box _____

PRESCRIPTION PAPER O2 VRA No 000000

Name of the Health Institution ______________________ Date: _______
Patient’s Name: __________________________ Sex: _____ Age: ______
Weight: ______ Card No. _______ … Inpatient … Outpatient
… Start … Refill
Diagnosis (ICD code No.) _________________________
Address: Region: _______________ Town _______ Woreda ______
Kebele ____ House No. ______ Tel. No._____________
Treatment given Price of each item
(Drug name, strength, dosage form, (for dispenser’s use only)
dose, duration, and quantity)
Rx

TOTAL

Prescriber’s Dispenser’s
Full name _________________________ ___________________
Qualification ______________________ ___________________
Registration _______________________ ___________________
Signature _________________________ ___________________
* See overleaf

61
 Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

FORMS MODIFIED IN THIS EDITION

Some of the tools/formats used in the recording, compilation and reporting of ARV drug
transactions are modified to reflect current practices and realities. The increase in the number
of ARV drugs, the need to track some of the regimens which were previously reported
grossly as others, the need to have more information on pediatric patients, their regimens and
consumption are some among many of the reasons that has resulted in modification of the
formats.

The following is the lists of modified forms and their design is described in the subsequent
pages:
1. Ordering and Receiving Form
2. Registers and Compilation Formats:
a. ARV Drugs Dispensing Register for Adults (ARV/DRA-06)
b. Monthly ARV Drugs Dispensing and Consumption Summary for Adults
(ARV/DCSA-06)
c. ARV Drugs Dispensing Register for Paediatrics (ARV/DRP-06)
d. Monthly ARV Drugs Dispensing and Consumption Summary for Pediatrics
(ARV/DCSP-06)
3. Reporting Formats:
a. Pharmacy Monthly ARV Drugs Activity Report for Adults (ARV/MARA-06)
b. Pharmacy Monthly ARV Drugs Activity Report for Pediatrics (ARV/MARP-
06)

62
 Additional Forms (Brief Explanations and Form Designs)
Ordering and Receiving Form (ARV/ORF-04)
Name of the Health Institution: ____________________________________________ Ref. No.
Requesting Section: Supplying Section:
S.N Items Ordered Items Supplied Items Received
Description Stock Quantity Quantity Expiry Batch Unit Total Quantity
Unit Remark/Discrepancy
(Name, strength, dosage form and pack size) on hand Ordered Supplied Date No Cost Cost Received

Ordered by: Approved by: Supplied by: Received/inspected by:

Signature: Signature: Signature: Signature:
Date: Date: Date: Date:
Delivery Mode: Delivering person: Signature:
Comments:

63
 TB. Treatment
Patients
Taking

Cotrimox. Prophylaxis
INH Prophylaxis
Quantity of Second Line Drugs Dispensed

IND 400mg
ABC 300mg
NFV 250mg
LOP/r 133/33 mg
ddi 400mg
ddi 250 mg
Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

ddI100mg
ddI 25mg
TDF 300mg
D4T40+3TC+NVP
ARV Drugs Dispensing Register for Adults (ARV/DRA-06)

D4T30+3TC+NVP
Quantity of First Line Drugs Dispensed

EFV 200mg
EFV 600mg
NVP 200mg
3TC 150mg
ZDV 300mg
ZDV+3TC 450mg
D4T 40mg
Name of the Health Institution: ____________________________

D4T 30mg
Others
ABC/3TC/LOP/r
ABC/ddI/NFV
Months of Supply Dispensed

TDF/ddI/LOP/r
TDF/ddI/NFV
ZDV/ddI/LOP/r
ZDV/ddI/NFV
ZDV/3TC/EFV
ZDV/3TC/NVP
D4T(40)/3TC/EFV
D4T(40)/3TC/NVP
D4T(30)/3TC/EFV
D4T(30)/3TC/NVP
Switch
for Visit
Reasons

Refill
Non-Naïve
Start
Naive
Refills Collected on time
Weight ≥ 60
Inpatient
Age ≥ 18
Age

12 ≥Age <18
Female
Sex Male
Card Number

64
Count

Sum
Date
Serial Number Total
 Deceased
Lost to follow-up
Total No of

Stopped treatment
Patients

Transferred out
Received PEP
65

TB. Treatment
Patients
Taking

Cotrimox. Prophylaxis
INH Prophylaxis
Year: _______________

IND 400mg of 180

Quantity of Second Line Drugs

ABC 300mg of 60
NFV 250mg of 270
Monthly ARV Drugs Dispensing and Consumption Summary for Adults (ARV/DCSA-06)

LOP/r 133/33 mg of
180
ddi 400mg of 30
ddi 250 mg of 30
Dispensed

ddI100mg of 60
ddI 25mg of 60
TDF 300mg of 30
Additional Forms (Brief Explanations and Form Designs)

D4T40+3TC+NVP of
60
D4T30+3TC+NVP of
60
Quantity of First Line Drugs Dispensed

EFV 200mg of 90
EFV 600mg of 30
NVP 200mg of 60
3TC 150mg of 60
ZDV 300mg of 60
Name of the Health Institution: ____________________________

ZDV+3TC 450mg of
60
D4T 40mg of 60
D4T 30mg of 60
Others
ABC/3TC/LOP/r
ABC/ddI/NFV
Months of Supply Dispensed

TDF/ddI/LOP/r
TDF/ddI/NFV
ZDV/ddI/LOP/r
ZDV/ddI/NFV
ZDV/3TC/EFV
ZDV/3TC/NVP
D4T(40)/3TC/EFV
D4T(40)/3TC/NVP
D4T(30)/3TC/EFV
D4T(30)/3TC/NVP
Switch
for Visit
Reasons

Refill
Star Non-Naive
t Naive
Refills Collected on time
Weight ≥ 60
Inpatient
Age ≥ 18
Age
12 ≥Age <18
Female

Sex
Male
Total No of Patients Since
Program Started
Monthe

Aug.
Nov.

Apr.

May
Mar
Sept

Dec.

Feb.

July
Jan.
Oct.

Jun
 Additional Forms (Brief Explanations and Form Designs)
Pharmacy Monthly ARV Drugs Activity Report for Adults (ARV/MARA-06)
Name of the Health Institution: ____________________________ Reporting Date: __________________
12 ≥Age <18
Age ≥ 18

D4T(30)/3TC/NVP
D4T(30)/3TC/EFV
D4T(40)/3TC/NVP
D4T(40)/3TC/EFV
ZDV/3TC/NVP
ZDV/3TC/EFV
ZDV/ddI/NFV
ZDV/ddI/LOP/r
TDF/ddI/NFV
TDF/ddI/LOP/r
ABC/ddI/NFV
ABC/3TC/LOP/r
Others

D4T 30mg of 60

D4T 40mg of 60

60
ZDV+3TC 450mg of

ZDV 300mg of 60

3TC 150mg of 60

NVP 200mg of 60

EFV 600mg of 30

EFV 200mg of 90

of 60
D4T30+3TC+NVP
of 60
D4T40+3TC+NVP

TDF 300mg of 30

ddI 25mg of 60

ddI100mg of 60

ddi 250 mg of 30

ddi 400mg of 30
180
LOP/r 133/33 mg of
NFV 250mg of 270

ABC 300mg of 60
IND 400mg of 180

INH Prophylaxis
Cotrimox. Prophylaxis
TB. Treatment
rt
Sta
Refill
Switch
Female
Male

Naive

Total Non-Naive

Coun
t

Total
Sum

Total No of PEP =
PEP Drugs Issued for PEP
_______
Emergency
Drugs Issued For: Transfer to Other Facilities
Return to Supplier

Stock on hand at the beginning of the

Total # Active Clients at the Facility month
Since the Program Started:
___________
Quantity received during the month

Stock on hand at the end of the month

Total # Patients (this month): Quantity on Order

ƒ Transferred out: _______ Quantity damaged or expired during the
ƒ Stopped t/t: _______ month
Quantity short dated (< 6 months)
ƒ Lost to follow-up: _______
ƒ Died: _______ No of days out of stock during the month

Name Signature Date Copies sent to:

Medical Director
Report prepared by: ___________________________ _______________ ___________
RHB/WHD
Report checked by: ___________________________ _______________ ___________ MSH/RPM Plus
Report distributed by: ___________________________ _______________ ___________

66
 TB. Treatment
Patients
Taking

Cotrimox.
Prophylaxis
67

INH Prophylaxis
Quantity of Second Line Drugs Dispensed

RTV 80mg/ml
RTV 100mg
ABC 20mg/ml
ABC 300mg
DDI (2g) Soln
DDI 25mg
DDI 100mg
NFV 250mg
LOP/r (80/20)
Soln
LOP/r 133/33mg
EFV 30mg/ml
ARV Drugs Dispensing Register for Paediatrics (ARV/DRP-06)

EFV 200mg
EFV 100mg
EFV 50mg
Additional Forms (Brief Explanations and Form Designs)

NVP 10mg/ml
NVP 200mg
Quantity of First Line Drugs Dispensed

3TC 10mg/ml
3TC 150mg
ZDV 10mg/ml
ZDV 300mg
ZDV 100mg
D4T (200mg)
Soln
D4T 30mg
Name of the Health Institution: ____________________________

D4T 20mg
D4T 15mg
Others
ABC/ddI/LOP/r
Months of Supply Dispensed

ABC/ddI/NFV
ZDV/ddI/LOP/r
ZDV/ddI/NFV
ZDV/3TC/LOP/r
ZDV/3TC/EFV
ZDV/3TC/NVP
D4T/3TC/EFV
D4T/3TC/NVP
Switch
for Visit
Reasons

Refill
Star Non-
t Naive
Refills Collected on time
Inpatient
6<age≤12 Years
3<Age≤6 Years
Age

Age ≤ 3 Years
Female
Sex Male
Card Number

Count
Sum
Date
Total
 Deceased
Total No of

Lost to follow-up
Patients

Stopped treatment
Transferred out
Received PEP
TB. Treatment
Patients
Taking

Cotrimox. Prophylaxis
INH Prophylaxis
Quantity of Second Line Drugs Dispensed
Year: ________________

RTV 80mg/ml of 450

RTV 100mg of 336
ABC 20mg/ml of 240
Monthly ARV Drugs Dispensing and Consumption Summary for Pediatrics (ARV/DCSP-06)

ABC 300mg of 60
DDI Soln (2g)
Standard Operating Procedures for Antiretroviral Drug Management at Health Facilities: Guidelines for Forms

DDI 25mg of 60
DDI 100mg of 60
NFV 250mg of 270
LOP/r (80/20) Soln of 300
LOP/r 133/33mg of 180
EFV 30mg/ml of 180
EFV 200mg of 90
EFV 100mg of 30
EFV 50mg of 30
NVP 10mg/ml of 240
NVP 200mg of 60
Quantity of First Line Drugs Dispensed

3TC 10mg/ml of 240

3TC 150mg of 60
ZDV 10mg/ml of 240
ZDV 300mg of 60
ZDV 100mg of 100
Name of the Health Institution: ____________________________

D4T Soln (200mg)

D4T 30mg of 60
D4T 20mg of 60
D4T 15mg of 60
Others
ABC/ddI/LOP/r
Months of Supply Dispensed

ABC/ddI/NFV
ZDV/ddI/LOP/r
ZDV/ddI/NFV
ZDV/3TC/LOP/r
ZDV/3TC/EFV
ZDV/3TC/NVP
D4T/3TC/EFV
D4T/3TC/NVP
Switch
for Visit
Reasons

Refill
Start Non-Naive
Naive
Refills Collected on time
Inpatient
6<age≤12 Years
3<Age≤6 Years

Age
Age ≤ 3 Years
Female

Sex

68
Male
Total No of Patients Since
Program Started

Mar
Sept

Dec.

Feb.
Jan.

July

Aug
Nov

Nay
Apr

Jun
Oct
Month

.
 Additional Forms (Brief Explanations and Form Designs)
Pharmacy Monthly ARV Drugs Activity Report for Pediatrics (ARV/MARP-06)
Name of the Health Institution: ____________________________ Reporting Date: ________________

Refills Collected on time

Sex Age Reasons Months of Supply Dispensed Quantity of First Line Drugs Dispensed Quantity of Second Line Drugs Dispensed Patients
for Visit Taking

D4T/3TC/NVP
D4T/3TC/EFV
ZDV/3TC/NVP
ZDV/3TC/EFV
ZDV/3TC/LOP/r
ZDV/ddI/NFV
ZDV/ddI/LOP/r
ABC/ddI/NFV
ABC/ddI/LOP/r
Others

D4T 15mg of 60

D4T 20mg of 60

D4T 30mg of 60

D4T Soln (200mg)

ZDV 100mg of 100

ZDV 300mg of 60

ZDV 10mg/ml of 240

3TC 150mg of 60

3TC 10mg/ml of 240

NVP 200mg of 60

NVP 10mg/ml of 240

EFV 50mg of 30

EFV 100mg of 30

EFV 200mg of 90

EFV 30mg/ml of 180

LOP/r 133/33mg of 180

LOP/r (80/20) Soln of 300

NFV 250mg of 270

DDI 100mg of 60
DDI 25mg of 60
DDI Soln (2g)
ABC 300mg of 60
ABC 20mg/ml of 240
RTV 100mg of 336
RTV 80mg/ml of 450

INH Prophylaxis
Cotrimox. Prophylaxis
TB. Treatment
Start
Refill
Switch
Inpatient
6<age≤12 Years
3<Age≤6 Years
Age ≤ 3 Years
Female
Male

Naive

Non-Naive

Total :
Count

Total:
Sum

PEP Total No of PEP = ______ Drugs Issued for PEP

Emergency
Drugs Issued For: Transfer to Other Facilities
Return to Supplier
Stock on Hand at the
Total # Active Clients at the Facility beginning of the month
Since the Program Started: ___________ Quantity received during the
month
Stock on hand at the end of the
month
Quantity on Order
Total # Patients (this month): Quantity damaged or expired
ƒ Transferred out: _______ during the month
Quantity short dated
ƒ Stopped t/t: _______ (<6months)
ƒ Lost to follow-up: _______ No of days out of stock during
ƒ Died: _______ the month

Name Signature Date Copies sent to:

Report prepared by: ___________________________ _______________ ___________ Medical Director
Report checked by: ___________________________ _______________ ___________ RHB/WHD
MSH/RPM Plus
Report distributed by: ___________________________ _______________ ___________

69