DRAFT MORTALITY AUDIT FORM FOR HIV / TB / HEI CLIENTS

Instructions: Fill section A for all clients, section B for HEIs, section C for PLHIV, TB/HIV coinfected and
PMTCT clients, and section D to F for all TB patients who died while on TB treatment and Section G to H for
all clients

Also refer to the detailed instructions page for further guidance.

Abstractor’s Name__________________________

Date of abstraction __ __/__ __/__ __ ____(DD/MM/YEAR)

County____________________________________

Sub County_________________________________

Facility Name_______________________________ MFL code _____________________

Patient Unique CCC number:

NUPI:

TIBU ID:

SECTION A: DEMOGRAPHICS (Fill for all patients)

1. Date of birth: __ __/__ __/__ __ __ __(DD/MM/YYYY)

2. Date of death: __ __/__ __/__ __ __ __(DD/MM/YYYY)

3. Date corresponding to 12 months __ __ / __ __ / __ __ __ __ (DD/MM/YYYY)

prior to death (time period of
interest)
4. Age at death: ____ (Years) OR ____ (Months for children under 2yrs)

5. Sex: Male Female

6. Marital Status: Single Married Divorced/Separated Widowed

☐ N/A

7. Pregnant or breastfeeding Pregnant Breastfeeding N/A

8. Occupation:

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 9. Caregiver Information (For Child Primary Caregiver
Mortalities) ☐ Mother ☐ Father ☐ Grandparents ☐ Others

HIV status of care giver

☐ Positive ☐Negative ☐ Unknown

Highest Education level:

☐ None ☐ Primary ☐ Secondary ☐Tertiary

Occupation: Specify: ____________________

SECTION B: HIV EXPOSED INFANT AUDITS (Fill only for HEIs)

MATERNAL TREATMENT INFORMATION
1. Entry point of the mother ☐ ANC: Indicate Gestation Age_____________
☐ Labor and Delivery
☐ Post Natal Clinic
☐ Not Documented
☐ Other In patient (surgical, medical etc)
☐ General Outpatient
☐ Others – E.g. Community
2. Date Maternal HIV Diagnosed __ __/__ __/ __ ___ ___ ____ (DD/MM/YYYY)

3. WHO stage at PMTCT enrolment ☐ Stage 1 ☐ Stage 2 ☐ Stage 3 ☐ Stage 4 ☐ Unknown

4. Maternal HAART Details ☐Already on ART ☐Newly initiated ART ☐ Declined ART

5. Date ART Initiated & Regimen __ __/__ __/ __ ___ ___ ____ (DD/MM/YYYY)
Regimen: ___________________

6. Most recent nutritional __ __/__ __/__ __ __ __(DD/MM/YYYY)

Assessment Weight ………………………………. BMI………………………
Height ………………………………...MUAC ………………….

7. Most Recent VL Results: LDL 200-999 c/mL >1000c/mL Not Done

Date VL Done: __ __/__ __/__ __ __ __(DD/MM/YYYY)

8. VL at PMTCT enrolment (if Known Results: LDL 200-999 c /mL >1000c /mL Not Done
Pos)
Date Done: __ __/__ __/__ __ __ __(DD/MM/YYYY)

9. HIV Disclosure Status ☐ Disclosed ☐ Not Disclosed ☐ Unknown

10. Adherence History ☐ Satisfactory ☐ Fair ☐ Poor

☐ Unknown

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 11. Any OIs in the perinatal Period Diagnosis____________-TX completed, Not Treated/incomplete

12. NCD Status of the mother; borrow Newly Diagnosed Diabetic(<3Mo from diagnosis) Known Diabetic
from NCD section below New Hypertension (<3Mo from diagnosis) ✘ Known Hypertension
Chronic kidney disease ☐ Liver disease ☐Mental health disease
Ischemic heart diseases, heart failure, ☐ Lung disease e.g. asthma,
COPD ☐Cancer ☐None Other
Specify other (s) type of co morbidity __________________________

HEI FOLLOW UP INFORMATION

13. HEI Unique ID Number:

14. Date HEI Enrolled __ __/__ __/__ __ __ __(DD/MM/YYYY) or Unknown

15. Age at HEI enrollment _____________ Weeks __________ (Months)

16. Place of delivery Health Facility Home Delivery Unknown

17. Mode of Delivery SVD Breech Delivery C/S Unknown

18. Infant Feeding (below 6 months) Excl. Breast Feeding Replacement Feeding
Mixed Feeding Unknown
19. HIV Diagnosis 1st PCR Date: __________ Results: _________ Not Done

2nd PCR Date: __________ Results: _________ Not Done

3rd PCR Date: __________ Results: _________ Not Done

Final AB test Date: _______Results: _________ Not Done

20. Infant Prophylaxis for PMTCT Yes (Type)_____________ Not Issued

21. What was the Morisky Medication 0 (Good) 1- 2 (Inadequate) 3 – 4 ( Poor) Unknown
Adherence Scale (MMAS-4) score
for child in the last visit? Assess the
number of missed doses
22. Immunization Status UpToDate Missed schedules Not Documented

23. Recent Growth and Nutritional Growth assessment

Assessment; Adopt what’s in ☐Undernutrition ☐Moderate acute Malnutrition ☐Severe Acute
practice. Malnutrition ☐Obese ☐Overweight ☐ Not Assessed

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 24. Developmental assessment Development assessment
☐ Normal ☐ Delayed ☐ Regressed ☐ Not Done

NOTE: If mortality occurs after the child had been linked to treatment, account for this child in the mortality audit
section C

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 SECTION C: HIV CARE AND TREATMENT (Fill for PLHIV, TB/HIV coinfected and PMTCT
clients)
BASELINE ASSESSMENT AND ART HISTORY
1. Date of HIV diagnosis: __ __/__ __/ __ ___ ___ ____ (DD/MM/YYYY) or
☐Unknown ☐ N/A (for HEI)
2. Date of enrollment into care: __ __/__ __/__ __ __ __(DD/MM/YYYY) or ☐Unknown

3. WHO clinical stage at ☐ Stage 1 ☐ Stage 2 ☐ Stage 3 ☐ Stage 4 ☐ Unknown

enrollment/baseline:
4. Date of baseline WHO staging: __ __/__ __/__ __ __ __(DD/MM/YYYY) or ☐Unknown

5. WHO clinical stage at time of ☐ Stage 1 ☐ Stage 2 ☐ Stage 3 ☐ Stage 4 ☐ Unknown

death
6. Date of ART initiation: __ __/__ __/__ __ __ __(DD/MM/YYYY) or ☐Unknown
7. Duration on ART (from ☐<6months ☐ 6-12 months ☐ >1yr
initiation to death)
8. ART Regimens for the client Initial Regimen and date of
and any changes in between start
from initial regimen to the Reasons for change
regimen at the time of death: 2nd Regimen and date of
(e.g ABC/3TC/LPV/r) and switch
reasons for change of regimen Reasons for Change
(Treatment failure, ART
optimization, adverse drug 3rd Regimen and date of
reaction, others-specify) switch
Reasons for Change
4th Regimen and date of
switch
Reasons for Change
Regimen at the time of death

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 BASELINE SCREENING AND INTERVENTIONS FOR ADVANCED HIV DISEASE
1. CD4 count done at Done Not done
baseline/enrollment?
2. CD4 count at baseline/ enrollment: CD4 Count ________ CD 4 % (for children) _______
3. Date of baseline CD4 test: __ __/__ __/__ __ __ __(DD/MM/YYYY) or Unknown

4. For those with CD4 <200, was Yes No Unknown

CTX/Dapsone given
5. For adolescents and adults with CD4 Yes No unknown
<200, CRAG test done
6. If yes to above, CRAG result? Pos Neg unknown

7. Was an, LP done? Yes No unknown

8. For those LP done results Crag

Pos Neg unknown
TB
Pos Neg unknown
9. For those positive, were they Yes No Unknown
treated?
10. Please specify the antifungal Liposomal Amphotericin + Flucytosine
regimen given Amphotericin B deoxycholate + Flucytosine
Amphotericin B deoxycholate +Fluconazole
Other, specify

11. For those pos LP, treatment Yes No Unknown

completed including secondary
prophylaxis until CD4 recovery?
12. Was, pre-emptive treatment (Crag Yes No Unknown
Pos-LP Neg/without signs of
meningism) with fluconazole given?
13. TB LAM done for those with CD4 Yes ☐ No ☐Unknown
<200
14. TB Diagnosed Yes ☐ No
15. Type of TB Bacteriologically Confirmed Clinically Diagnosed

16. For those TB pos, TB Treatment Yes No Unknown

given
TREATMENT MONITORING AND FOLLOW UP
1. Is there a more recent CD4 count Yes, there is a more recent CD4 No, baseline us the most recent
(other than the baseline): CD4
2. Date of most recent CD4 count: __ __/__ __/__ __ __ __(DD/MM/YYYY) or Unknown

3. What was the CD4 count < 200 cells/ml >200 cells/ml or
CD4% <25%, CD4 % > 25 ☐ Not available
4. Patient had a valid VL test result? Yes No /ineligible No /eligible
(Done in the last 12months)
5. If yes to above question, what were Date of VL Result LDL 200 -999 >1000
the viral load results for the test
done in the last 1 year:

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 6. Date and result of most recent VL __ __/__ __/__ __ __ __(DD/MM/YYYY) or Unknown
test if no VL done in the last 1 year
(12 months): <1000 >1000

7. VL result for care giver and date Yes No /ineligible No /eligible

(For child mortalities) __ __/__ __/__ __ __ __(DD/MM/YYYY) or ☐Unknown

8. Did the patient have any adverse ☐ Yes ☐ No

drug reaction to ARVs? (check the If yes, specify the type of ADR and grade below
last 12months prior to death) ☐ Rash: ☐ Grade I ☐ Grade II ☐ Grade III ☐ Grade IV
☐ Not graded
☐ Hepatitis: ☐ Grade I ☐ Grade II ☐ Grade III ☐ Grade IV
☐ Not graded
☐ Peripheral Neuropathy: ☐ Grade I ☐ Grade II ☐ Grade III
☐ Grade IV ☐ Not graded
☐ Other
Specify other type (s) of adverse drug reaction and grade below:
____________________________________________
☐ Grade I ☐ Grade II ☐ Grade III ☐ Grade IV☐ Not graded

9. Were there any drug-drug ☐ Yes ☐ No ☐Unknown

interactions during anti-retroviral
therapy (Check the 12 months prior
to death?)

10. If yes to the above specify the ☐ Rifampicin with DTG

suspected drugs ☐ Metformin with DTG
☐ Polyvalent cations with DTG (e.g., Calcium supplements, iron
supplements, Magnesium/Aluminum containing antacids)
☐ Anticonvulsants with DTG (e.g., carbamazepine, phenobarbital,
phenytoin)
☐ Other, please specify: ______________

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 TB EVALUATION
1. Has the client ever been initiated on Yes No Unknown
TPT?
Initiation date __ __/__ __/__ __ __ __(DD/MM/YYYY)
2. If yes, indicate the outcome of TPT ☐ Treatment Completed (Indicate completion date below)
☐ Discontinued ☐ Lost to follow up ☐Died ☐ Transferred out
If discontinued, indicate reason for stopping ______________________
Date if TPT was completed __ __/__ __/__ __ __ __(DD/MM/YYYY)
3. Was the client ever diagnosed with Yes No
presumptive TB in the last 12
months prior to death?
4. If yes to the above, were TB Yes No
investigations done?
5. Was the client diagnosed with TB in
Yes No
the last 12 months prior to death?
If yes specify type of TB
☐ Pulmonary Bacteriologically Confirmed
(If the client died while on TB
medication update section D-F below)
☐ Pulmonary TB Clinically Diagnosed
☐ EPTB (Specify location)____________
ADHERENCE AND APPOINTMENT MANAGEMENT
1. Was the patient adhering to clinic Kept all scheduled appointments
appointments for HIV medication? Missed appointment(s), but not defaulted (missed but came back
(Check the 12 months prior to death) within 7 days)
Defaulted and traced back (missed clinic for more >7 days but came
back before 30 days)
Lost to follow up but returned to treatment (did not came to clinic
for >30 days after last expected visit, but RTT)
Lost to follow up but NOT returned to treatment

2. Were clinic appointments ☐ Yes, ☐ No Unknown

synchronized with caregivers (for
child mortalities)

3. Did the client honor their last Yes, No Unknown

expected clinic appointment?
4. What was the Morisky Medication 0 ( Good ) 1- 2 ( Inadequate ) 3 – 4 ( Poor) Unknown
Adherence Scale (MMAS-4) score for
the client in the last visit?
5. Was TB screening done in the last Yes No Unknown
clinic visit (check from ICF)?
6. If yes, result of the TB screen? Yes to 1 or more of the questions,
No to all questions

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 SECTION D: TB DIAGNOSIS /TREATMENT AND ADHERENCE ASSESSMENT AND HIV STATUS
EVALUATION (Fill section D, E, F for clients who were TB positive but HIV negative, if they were TB/HIV
coinfected fill section C above and D, E, F as well)
1. Source of patient Referred from outside of facility
Referred from within facility
Self-referral

2. Primary method of TB diagnosis Culture Gene X pert AFB Smear Microscopy

(Only choose one) LAM X ray Other (Specify) __________________________

3. Date of TB diagnosis __ __/__ __/ __ ___ ___ ____ (DD/MM/YYYY)

4. Type of TB Type of TB:

Pulmonary Bactriologically Confirmed
Pulmonary TB Clinically Diagnosed
EPTB (Specify location)____________

Confirmed Drug Resistance: Yes No

If drug resistant specify type below: Rifampicin Resistance
INH Monoresistance Other Monoresistance Polyresistance
MDR Pre XDR XDR

New Treatment after loss to follow up Relapse

5. Type of Patient Previous Treatment History Unknown
Treatment after failure Others previously treated

TB TREATMENT
6. (a)Was the patient initiated on anti- Yes ( If yes indicate initiation date below ) No
TB treatment?
__ __/__ __/ __ ___ ___ ____ (DD/MM/YYYY)
Time from TB diagnosis to anti-TB drug initiation (days) __________

(b)If yes, which anti-TB regimen 2RHZE/4RH 2RHZE/10RH MDR regimen ( specify below)
was patient initiated on? Other specify _____________________

(c)Which anti-TB regimen was 2RHZE/4RH 2RHZE/10RH MDR regimen ( specify below)
patient on at the time of death? Other specify__________________

7. (a)Was nutritional assessment Yes No Unknown

conducted for the patient at the last
visit or within the month prior to
death?
(b) If yes, what were the BMI _____ MUAC ____ Z Score ____
anthropometric findings? __ __/__ __/__ __ __ __(DD/MM/YYYY)
Indicate date

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 8. Which interventions did the patient Therapeutic feeds Nutritional Counselling Vitamin A
receive? Pyridoxine Supplementary None

9. TB treatment outcome/status at Defaulted Active on treatment Unknown

death
ADHERENCE TO TB TREATMENT
10. Check if the patient attended Intensive phase:
scheduled visits during TB Attended all scheduled visits Missed a visit(s) and traced back
treatment. Missed a visit (s) and not traced back
Continuation Phase:
Attended all scheduled visits Missed a visit(s) and traced back
Missed a visit (s) and not traced back

11. Did the client have an adverse drug Yes No

reaction to anti-TB medication? If yes, specify the type of ADR and grade below.
Rash: Grade I Grade II Grade III Grade IV
Not graded
Hepatitis: Grade I Grade II Grade III Grade IV
Not graded
Peripheral Neuropathy: Grade I Grade II Grade III
Grade IV Not graded
Other
Specify other type (s) of adverse drug reaction and grade below:
____________________________________________
Grade I Grade II Grade III Grade IV Not graded

12. Were there any drug–drug ☐ Yes ☐ No

interactions between anti-TB and
other medications during TB If yes, specify ______________________________
treatment?
HIV DIAGNOSIS FOR TB PATIENTS
13. Was a HIV test done for the client? Yes No

14. Date of HIV test __ __/__ __/ __ ___ ___ ____ (DD/MM/YYYY)

15. HIV test result Positive Negative Unknown/Indeterminate

16. If positive, was the client enrolled in Yes No

HIV care?

For all HIV positive TB patients update section C above

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 SECTION E: CAUSE OF DEATH (fill for all clients based on multidisciplinary team discussions)
1. Was the patient diagnosed Yes No Unknown
with any opportunistic
infection in the 12 months
prior to death?
2. Specify infections
diagnosed:
3. Did the patient have any Newly Diagnosed Diabetic(<3Mo from diagnosis) Known Diabetic New
NCD co-morbidity prior to Hypertension (<3Mo from diagnosis) ✘ Known Hypertension
death? (Tick all that apply)
Chronic kidney disease ☐ Liver disease ☐Mental health disease
Ischemic heart diseases, heart failure, ☐ Lung disease e.g. asthma, COPD
☐Cancer ☐None Other
Specify other (s) type of co morbidity __________________________

4. If yes to above, was/were the NCD Yes No Unknown

NCD well controlled?
(Specify the NCD)

5.
6. Place of death In patient health facility ☐ Outpatient health facility Home
Other ☐ Unknown

7. Possible contributors to Drug/ Substance Abuse Advanced HIV Disease; undiagnosed or

cause of death from the partially treated or untreated OI Malnutrition HIV Treatment failure
variables above? (Check
Adverse drug reactions ☒ ☐Prior infectious disease sequalae ☐ TB
any/all that apply)
treatment failure ☐ Drug interactions
Other OIs Other Co morbidities Specify..................................

8. What was the probable (a)IMMEDIATE CAUSE; disease or condition directly leading to death
cause of death? _____________________________due to (or as a consequence of)

(b)ANTECEDENT morbid conditions, if any, giving rise to the above cause,

__________________________due to (or as a consequence of

(c)UNDERLYING CONDITION __________________________ due to (or as

a consequence of)

OTHER SIGNIFICANT CONDITIONS contributing to the death, but not related

to the disease or condition causing
it_........................___________________________________________________
Any Additional Comments:

…………………………………………………………………………......................................................................

………..………………………………………………………………………………………………………………

SECTION H: Recommendations for improvement (based on multi- disciplinary team discussion)

Gap Noted Key Action Responsible Person Timeline

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1.

2.

3.

4.

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