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Monthly Service Delivery Report Form

This document appears to be a monthly service delivery report form for a private clinic to report reproductive, maternal, neonatal, child and adolescent health services and metrics. It includes over 80 line items grouped under categories like contraceptive services, antenatal care, delivery services, postnatal care, abortion care, fistula treatment and PMTCT. The form collects data on service utilization by age, gestational age and other demographic factors to monitor and evaluate the clinic's performance.

Uploaded by

Iyaadan
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© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
91 views

Monthly Service Delivery Report Form

This document appears to be a monthly service delivery report form for a private clinic to report reproductive, maternal, neonatal, child and adolescent health services and metrics. It includes over 80 line items grouped under categories like contraceptive services, antenatal care, delivery services, postnatal care, abortion care, fistula treatment and PMTCT. The form collects data on service utilization by age, gestational age and other demographic factors to monitor and evaluate the clinic's performance.

Uploaded by

Iyaadan
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Monthly Service Delivery Report Form.

Private Clinic Name ____________________ Month___________


Year ____________

HMIS_code Activity Number


Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health-
RMNCH
Nutrition
RMH Reproductive & Maternal Health
MAT_CAR Contraceptive acceptance rate
MAT_CAR_Age Total new and repeat acceptors, disaggregated by age
MAT_CAR_Age.1 Contraceptive new acceptors by age
MAT_CAR_Age.1.1 10 - 14 years
MAT_CAR_Age.1.2 15 - 19 years
MAT_CAR_Age.1.3 20 - 24 years
MAT_CAR_Age.1.4 25 - 29 years
MAT_CAR_Age.1.5 30 - 49 years
MAT_CAR_Age.2 Repeat acceptors by age
MAT_CAR_Age.2.1 10 - 14 years
MAT_CAR_Age.2.2 15-19 years
MAT_CAR_Age.2.3 20 - 24 years
MAT_CAR_Age.2.4 25 -29 years
MAT_CAR_Age.2.5 30 - 49 years
MAT_CAR_Mtd Total new and repeat acceptors, disaggregated by method
MAT_CAR_Mtd.1 New acceptors, by method
MAT_CAR_Mtd.1.1 Oral contraceptives
MAT_CAR_Mtd.1.2 Injectables
MAT_CAR_Mtd.1.3 Implants
MAT_CAR_Mtd.1.4 IUCD
MAT_CAR_Mtd.1.5 Vasectomy
MAT_CAR_Mtd.1.6 Tubal ligation
MAT_CAR_Mtd.1.7 Others
MAT_CAR_Mtd.2 Repeat acceptors, by method
MAT_CAR_Mtd.2.1 Oral contraceptives
MAT_CAR_Mtd.2.2 Injectables
MAT_CAR_Mtd.2.3 Implants
MAT_CAR_Mtd.2.4 IUCD
MAT_CAR_Mtd.2.5 Vasectomy
MAT_CAR_Mtd.2.6 Tubal ligation
MAT_CAR_Mtd.2.7 Others
MAT_IPPCAR Immediate Postpartum Contraceptive Acceptance(IPPCAR)
MAT_IPPCAR_Age Total PPFP acceptors, disaggregated by age
MAT_IPPCAR_Age.1 10 - 14 years
MAT_IPPCAR_Age.2 15-19 years
MAT_IPPCAR_Age.3 20 - 24 years
MAT_IPPCAR_Age.4 25 -29 years
MAT_IPPCAR_Age.5 30 - 49 years
MAT_IPPCAR_Mtd Total PPFP acceptors, disaggregated by method
MAT_IPPCAR_Mtd.1 Pills(POP)
MAT_IPPCAR_Mtd.2 Implants
MAT_IPPCAR_Mtd.3 IUCD
MAT_IPPCAR_Mtd.4 Tubal Ligation
MAT_IPPCAR_Mtd.5 Others
MAT_LAFPPR Premature Removal of Long term family planning methods (PRLAFP)
MAT_LAFPPR.1 Total number of premature removal of LAFP within 6 month insertion
MAT_LAFPPR.1.1 Implants
MAT_LAFPPR.1.2 IUCD
MAT_LAFPPR.1.3 Others
MAT_TLAFPR Total LAFP removal in the reporting period
MAT_ANC1 Antenatal Care coverage -First visit

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Total Number of pregnant women that received ANC First visit by
MAT_ANC1_GA.1
gestational Age
MAT_ANC1_GA.1.1 <= 12 weeks
MAT_ANC1_GA.1.2 > 12 and <=16 weeks
MAT_ANC1_GA.1.3 > 16 weeks
MAT_ANC1_MA.1 Number of pregnant women that received ANC first visit by maternal age
MAT_ANC1_MA.1.1 10-14 years
MAT_ANC1_MA.1.2 15-19 years
MAT_ANC1_MA.1.3 >= 20 years
MAT_ANC4+ Antenatal care coverage - four visits
Total number of pregnant women that received four antenatal care visits
MAT_ANC4+_GA.1
by gestational age
MAT_ANC4+_GA.1.1 < 30 weeks
MAT_ANC4+_GA.1.2 > = 30 weeks
MAT_ANC4+_MA.1 Total number of pregnant women that received four antenatal care visits
MAT_ANC4+_MA.1.1 10-14 years
MAT_ANC4+_MA.1.2 15-19 years
MAT_ANC4+_MA.1.3 >= 20 years
MAT_ANC8+ Antenatal care coverage - Eigth visits
Number of pregnant women that received antenatal care –8 Contacts
MAT_ANC8+
and more
MAT_SYPH Pregnant women attending antenatal care tested for syphilis
MAT_SYPH.1 Total Number of pregnant women tested for syphilis
MAT_SYPH_Rct.1 Test result-Reactive
MAT_SYPH_NRct.1 Test Result- Non-Reactive
MAT_SYPH.RX.1 Total Number of pregnant women treated for syphilis
Total Number of Pregnant women attending antenatal care tested for
MAT_Hepa
hepatitis (B&C)
MAT_Hepa_Rct.1 Test result :Reactive
MAT_Hepa_NRct.1 Test result :Non-Reactive
MAT_Prp Proportion of pregnant women who were received prophylaxis for HBV
Total Number of pregnant women who were received prophylaxis for
MAT_Prp.1
HBV
MAT_SBA Births attended by skilled health personnel coverage
MAT_SBA.1 Total Number of births attended by skilled health personnel
MAT_PPH Percentage of women who developed Postpartum hemorrhage (PPH)
MAT_PPH.1 Total number of women who developed postpartum hemorrhage (PPH)
MAT_PPH.Hom.1 Home delivery
MAT_PPH.facil.1 Facility delivery
Percentage women who received uterotonics in the first one minute after
MAT_UTER
delivery
Total number of women who received uterotonics in the first one minute
MAT_UTER.1
after delivery
MAT_UTR.type.1.1 Oxytocin
MAT_UTR.type.1.2 Mesoprostol
MAT_UTR.type.1.3 Ergometrin
MAT_UTR.type.1.4 Other
MAT_SBR Still birth rate
MAT_SBR.SB Number of still births
MAT_SBR.LB Number of Live births
MAT_B&D Birth and Death Notifications
MAT_B&D_IBN.1 Number of Institutional Births notified
MAT_B&D_IDN.2 Number of Institutional death notified
MAT_EPNC Early Postnatal Care Coverage
MAT_EPNC.1 Number of postnatal visits within 7 days of delivery
MAT_EPNC.1.0 Early first postnatal care attendances 0-24 hrs
MAT_EPNC.1.1 Early first postnatal care attendances 24 hrs (1 days)
MAT_EPNC.1.2 Early first postnatal care attendances 25-48 hrs
MAT_EPNC.1.3 Early first postnatal care attendances 49-72 hrs

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MAT_EPNC.1.4 Early first postnatal care attendances 73hrs-7 days
MAT_CS Caesarean section rate
MAT_CS.1 Number of women having given birth by caesarean section
MAT_CAC Number of women receiving comprehensive abortion care services
MAT_CAC_SAC Number of safe abortions performed
MAT_CAC_SA.1 10-14 yr
MAT_CAC_SA.2 15-19 yr
MAT_CAC_SA.3 20-24 yr
MAT_CAC_SA.4 25-29 yr
MAT_CAC_SA.5 30+ yr
MAT_CAC_PAC Number of post abortion/emergency care
MAT_CAC_PAC.1 10-14 yr
MAT_CAC_PAC.2 15-19 yr
MAT_CAC_PAC.3 20-24 yr
MAT_CAC_PAC.4 25-29 yr
MAT_CAC_PAC.5 30+ yr
Number of women receiving comprehensive abortion care disaggregated
MAT_CAC.Tr.1
by trimester
MAT_CAC.Tr.1.1 First Trimester (<12 weeks)
MAT_CAC.Tr.1.2 Second Trimester (≥12 - 28 weeks)
Number of women receiving comprehensive abortion care disaggregated
MAT_CAC.MA.1
by Methods
MAT_CAC.MA.1.1 POP
MAT_CAC.MA.1.2 Implants
MAT_CAC.MA.1.3 IUCD
MAT_CAC.MA.1.4 Tuba Ligation
MAT_CAC.MA.1.5 Others
MAT_OFC.Ide Number of confirmed obstetric fistula cases identified
MAT_OFC_Ide__Age Number of confirmed fistula cases identified by Age
MAT_Ide_Age.1.1 10-14 yr
MAT_Ide_Age.1.2 15-19 yr
MAT_Ide_Age.1.3 20-24 yr
MAT_Ide_Age.1.4 25-29 yr
MAT_Ide_Age.1.5 30+ yr
MAT_OFC.Treat Proportion of obstetric fistula cases treated
MAT_OFC_Treat__Age Number of obstetric fistula cases treated by Age
MAT_Treat_Age.1.1 10-14 yr
MAT_Treat_Age.1.2 15-19 yr
MAT_Treat_Age.1.3 20-24 yr
MAT_Treat_Age.1.4 25-29 yr
MAT_Treat_Age.1.5 30+ yr
MAT_IMD Institutional maternal deaths
MAT_IMD.1 Number of maternal deaths in health facility
MAT_TngP_TPR Total number of teenage girls tested positive for pregnancy
MAT_TngP_TPR.1 10-14 years
MAT_TngP_TPR.2 15-19 years
MAT_Tngtst Total number of women tested for pregnancy
MTCT PMTCT
Pregnant and lactating women who were tested for HIV and know their
MTCT_TST
results
Number of pregnant women tested and know their result during
MTCT_TST.1
pregnancy
Number of pregnant women tested and know their result during
MTCT_TST.2
labour & delivery
Number of women tested and know their result during the
MTCT_TST.3
postpartum period
Number of women with known HIV positive status attending ANC,
MTCT_Test.4
delivery and postpartum for new pregnancy linked from Pre and ART
MTCT_NWpos Number of new Postive womens during ANC,L&D and Postpartum
MTCT_ART Percentage of HIV-positive pregnant women who received ART to reduce

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the risk of mother-to child-transmission (MTCT) during pregnancy, L&D and
PNC
Number of HIV positive Pregnant women who received ART to reduce
MTCT_ART.1
the risk of mother to child transmission during ANC for the first time
Number of HIV positive Pregnant women who received ART to reduce
MTCT_ART.2
the risk of mother to child transmission during L&D for the first time
Number of HIV positive lactating women who received ART to reduce
MTCT_ART.3
the risk of mother to child transmission during PNC for the first time
Number of HIV-positive women who get pregnant while on ART and
MTCT_ART.4
linked to ANC
MTCT_HEI_EID.1 Total Number of infants within 12 month received virological test result
Number of HIV exposed infants who received an HIV test 0- 2 months of
MTCT_HEI_EID.1.1
birth:
MTCT_HEI_EID.1.1.1 :Positive
MTCT_HEI_EID.1.1.2 :Negative
Number of HIV exposed infants who received an HIV test 2-12 months of
MTCT_HEI_EID.1.2
birth
MTCT_HEI_EID.1.2.1 :Positive
MTCT_HEI_EID.1.2.2 :Negative
Percentage of exposed Infants born to HIV positive women who were
MTCT_HEI_COTR
started on co-trimoxazole prophylaxis within two months of birth
Number of infants born to HIV positive women started on co-
MTCT_HEI_COTR.1
trimoxazole prophylaxis within two months of birth
Percentage of exposed Infants born to HIV positive women receiving
MTCT_HEI_ARV antiretroviral (ARV) prophylaxis for prevention of Women-to-child
transmission (PMTCT)
Number of HIV exposed infants who received ARV prophylaxis For
MTCT_HEI_ARV.1
12 weeks
MTCT_HEI_ARV.2 Number of HIV positive women who gave birth at health institution
Percentage of partners of pregnant, laboring and lactating women tested
MTCT_PMTCT_PRN_TST
for HIV in the reporting month/period
Total Number of partners of pregnant ,laboring and lactating women
MTCT_PRN_TST.1
tested and know their results
Number of partners of pregnant, laboring and lactating women whose
MTCT_PRN_TST.2
test result is HIV positive
Percentage of HIV exposed infants receiving HIV confirmatory (antibody
MTCT_HEI_ABTST
test) test by 18 months
Number of HIV exposed infants receiving HIV confirmatory (antibody
MTCT_HEI_ABTST.1
test) by 18 months
MTCT_HEI_ABTST_Pos.
HIV positive
1
MTCT_HEI_ABTST_Neg
HIV negative
.1

Reported by __________________________

Report sent date _____________

Signature ______________________

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