Unit 12: Reporting & Recording Botswana National Tuberculosis Programme Manual Training for Medical Officers

Unit 12: Reporting & RecordingUnit 12: Reporting & Recording

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Slide 12-2Unit 12: Reporting and Recording

ObjectivesObjectives

At the end of this unit, participants will be able to:

• Discuss the importance of collecting data

• Explain the ways in which data are used

• Describe details for completing each reporting form

• Practice completion of the Botswana Treatment Card


QuestionQuestion

How are TB Prevention and Control

activities monitored and evaluated?


Monitoring & Evaluation ActivitiesMonitoring & Evaluation Activities

• Completing reporting forms on case findings and treatment outcomes

• Supervisory visits

• Discussions during staff meetings

• Review of medicine stocks

• Staff training

• Follow-up

• Analysing data collected


QuestionQuestion

Why is accurate reporting

and record keeping important?


Importance of Importance of Reporting and Record KeepingReporting and Record Keeping

• It is an important part of the DOTS strategy

• It helps clinics, regions and the nation reach its programme goals

• It helps us know if our strategies are effective

• It allows us to see trends and to identify “hot spots” or high risk groups so that efforts can be targeted


Data Can Enhance Data Can Enhance Your Work By…Your Work By…

• Serving as positive reinforcement for a job well done

• Motivating staff to continue or improve their efforts

• Identifying areas of strengths and weaknesses

• Identifying training and supervision needs


Botswana TB R&R Forms (1)Botswana TB R&R Forms (1)

• TB Suspect and Sputum Dispatch Register

• Mycobacteriology Request Form

• TB Laboratory Register



• Facility/District TB Register

• Patient Appointment and DOT Card

• TB Contact Examination Form



• Electronic TB Register (ETR)

• Transfer of Patient

• MDR Treatment Card



• MDR Treatment Register

• IPT Dispensary Tally Sheet

• IPT Register and Compliance Record

• Tuberculosis Treatment Card


The TB Treatment Card (1)The TB Treatment Card (1)

• Initial source of data for the TB recording and reporting system

• Diagnosis and treatment information

• Should be completed by MDs and nurses

• Information from the treatment card is used to fill in the facility and district TB registers

• Information should be complete and accurate

• SOME data is better than NO data!!


The TB Treatment Card (2)The TB Treatment Card (2)


Name (Surname, First Name)Name (Surname, First Name)

The patient’s surname is written first, followed by the patient’s first name. If the patient has a middle name, write that in the space as well. Example: The patient’s name is Francis Mulenga


Sex Sex

• Circle the appropriate box for either male (M) or female (F)

• Example: Francis Mulenga is male, “M” should be recorded


Age (in years)Age (in years)

• Correct response for this column is age in years. If patient is a child under one year old, write the number of months followed by /12 (e.g., 6 months would be 6/12)

• If the patient doesn’t know their age:• Look on the OPD• Ask year of birth• Ask a family member


Omang/Passport #Omang/Passport #

• Fill in the 9-digit Omang number or Passport number of each TB patient in the space provided. If the patient does not have an identification number, leave this column blank.

• Example: Francis Mulenga’s Omang number is 123456789


Address in FullAddress in Full

• The best description of where the patient lives should be written in this section (street address or plot number). The HCW needs to know enough to FIND the person if s/he has to!!

• Example: Francis Mulenga lives in a blue house near the Shell petrol station in plot 45

• Request at least one mobile phone number for patient and close relative


Pretreatment History Pretreatment History and Clinical Findingsand Clinical Findings

• This section, below “Alternative address,” should be written in

• There are no codes


Registration and Registration and Transfer InformationTransfer Information

Unit TB No: The Unit TB number consists of four parts• A: District Number (2 digits)• B: Health facility Code number (3 digits)• C: Specific serial number of the patient starting with 001 at the

beginning of each year • D: Year of registration


Transfer Information (1)Transfer Information (1)

Transferred/Moved Out:• If a patient transfers to a facility in another district

during treatment (“transfer out”), or moves to another facility in the same reporting unit (“move out”), fill in the “To” column with the name of the health facility to which the patient transferred/ moved

• A separate BNTP form entitled Notice of Transfer of a Patient must be completed for all patients transferring or moving



Example: a patient with registration number “089/04” was moved out to Ext. 14 Clinic on 02 October 2004.



Transferred/Moved In:• Patients transferred or moved in from another

reporting unit to your health facility, should be (re-)registered in the TB register.

• Enter your unit TB number, along with the patient’s new registration number, in the second line of the box. Put an “X” in the “IN” column

• Note that this is a duplicate TB treatment card, as the original card remains at the original health facility



• The receiving clinic must complete the Response to a Transfer of a Patient and return to sending clinic.



• Do not fill in the “REGISTERED” column– it is just to state that the patient has been registered in your health facility. Record the date that the patient came into health facility

• Example: the patient was re-registered with the new registration number “078/04”, when he moved in to Ext. 14 Clinic on 15 October 2004


TB Classification (1)TB Classification (1)

• Purpose: Disease classification and site of disease should be recorded in this section

• Pulmonary disease means TB of the lungs, including patients that are smear-positive or smear-negative

• All other types of TB are classified as extrapulmonary disease, including pleurisy and miliary TB

• Patients with pulmonary AND extrapulmonary disease should be classified as pulmonary


TB Classification (2)TB Classification (2)

• Make an “X” over the appropriate box for pulmonary TB or extrapulmonary TB

• If the patient has both pulmonary and extrapulmonary TB, mark this as pulmonary TB and fill in the site of extrapulmonary TB

• In the case of extrapulmonary

TB, indicate the site that has

been affected in the space

provided • Example: Francis Mulenga

has pulmonary TB


Patient Category Patient Category

• Proper patient category necessary to determine appropriate treatment regimen

• Make an “X” over the box with the appropriate option. The four options are:• NEW• FAILURE• DEFAULT• RELAPSE

• Francis Mulenga is a new patient

RETREATMENT

CASES


Sputum Examination Results: Sputum Examination Results: Pre-Treatment (1)Pre-Treatment (1)

• Purpose: These columns record the date and results of the patient’s pre-treatment sputum smear result• In all cases (except young children), three sputum

examinations should be done (spot, morning, spot)


Sputum Examination Results: Sputum Examination Results: Pre-Treatment (2)Pre-Treatment (2)

• Date format: “dd/mm/yy”• Record date of collection

of sputum

• Results column: “P” for positive and “N” for negative• Indicate the grading of

the sputum result (i.e., scanty, +, ++, +++)


Sputum Exam Results: Sputum Exam Results: Pre-Treatment (3)Pre-Treatment (3)

Example: • Francis Mulenga gave

three sputum specimens for examination, one on 12th January and two on 13th January

• The results were “+++”, “++”, and “+++”, respectively


Sputum Exam Results: Sputum Exam Results: Intensive Phase (2 Month Exam) (1)Intensive Phase (2 Month Exam) (1)

• Purpose: Two sputum smears should be done after two months of treatment


• Date format: “dd/mm/yy”• Record date of collection of sputum

• Results column: “P” for positive and “N” for negative• Example: Francis Mulenga gave one sputum

specimen for examination on 15th March. The result was negative

Sputum Exam Results: Sputum Exam Results: Intensive Phase (2 Month Exam) (2)Intensive Phase (2 Month Exam) (2)


Sputum Exam Results: Sputum Exam Results: End of Treatment (6 months)End of Treatment (6 months)• Two sputum exams should

be done at the end of six months of treatment

• Date format: “dd/mm/yy”• Record date of collection

of sputum• Results column: “P” for

positive, “N” for negative • Example: Francis Mulenga

gave two sputum specimens for examination on 5th July. Results were negative


Sputum Smear Results:Sputum Smear Results:End of Treatment (8 months) End of Treatment (8 months)

• Category II patients should have two sputum examinations at eight months

• Date format: “dd/mm/yy”• Record date of

collection of sputum• Results column: “P” for

positive, “N” for negative


Pre-Treatment WeightPre-Treatment Weight

• This section records the patient’s weight prior to treatment, in kilograms

• Weigh the patient, record the value in the space provided

• Weight is essential to determine drug dosages


Initial Phase of TreatmentInitial Phase of Treatment

• Lists the fixed-dose combinations of anti-TB drugs for adults and children during the intensive phase of TB treatment

• Circle the anti-TB regimen that the patient is taking• Example: Francis Mulenga weighs 58 kg, so he will receive

the regimen circled


HIV Status (1) HIV Status (1)

• This section records up to two HIV test results for each TB patient

• Patients with a negative test result at the beginning of treatment should be re-tested within three months or before the end of treatment


HIV Status (2)HIV Status (2)

• Example: Francis Mulenga was tested HIV negative on 15 January 2005; make an “X” over the box indicating a negative result and record the date

• Francis Mulenga was retested two months later and had a positive test result; make an “X” over the box indicating a positive result and record the date

X 15/03/05


ART: Antiretroviral Therapy (1)ART: Antiretroviral Therapy (1)

• This section records TB patient history of, or concurrent treatment with ART, along with the date

• Make an “X” over the appropriate box• If the patient is on ART, or has a history of taking ART,

make an “X” in the “Yes” box• If the patient is HIV negative, leave the box blank• If the patient is HIV-infected, but is not on ART, leave the

box blank• Using the format “dd/mm/yy”, record the date in the

appropriate column


ART: Antiretroviral Therapy (2)ART: Antiretroviral Therapy (2)

• Example: The patient is not currently on ART; leave the ART status boxes blank


IPT (1) IPT (1)

• This section records whether the TB patient has received IPT prior to the current TB episode, along with the date IPT started

• Make an “X” over the appropriate box• If the patient has ever taken even one dose of IPT as part

of the IPT programme , make an “X” in the “Yes” box• If the patient has never taken IPT, make an “X” in the “No”

box• Using the format “dd/mm/yy”, record the date in the

appropriate column


IPT (2)IPT (2)

• Example: The patient received 3 months of IPT prior to developing TB; mark an “X” over the “YES” box on the treatment card

X

X

01/06/03

15/03/05


Other Tests: Biopsy, PPD, OtherOther Tests: Biopsy, PPD, Other

• This section records other test results for each TB patient, along with the date. Not all TB patients will have other tests, so this section may be left blank if it is not applicable

• Example: Francis Mulenga had a PPD result of 18 millimeters on 15 January 2005, but did not have a biopsy


Treatment Compliance Treatment Compliance

• To track patient adherence to anti-TB treatment on a daily basis. Records follow-up weight at end of each calendar month

• HCW should enter his/her initials on each day of supervised drug administration, a “-“ for self-supervised treatment, or a “0” for any missed treatment

• Example: Francis Mulenga began DOT on 15 January 2005, but on 22 January, he was unable to visit the clinic and missed that day of treatment. His follow-up weight at the end of January was 59.2 kilograms


Continuation Phase (1)Continuation Phase (1)

• This section lists the fixed-dose combinations of anti-TB drugs for adults and children during the continuation phase of treatment

• Record the patient’s follow-up weight

• Circle the anti-TB regimen that the patient is taking


Continuation Phase (2)Continuation Phase (2)

• Example: Francis Mulenga weighs 59.4 kg at the continuation phase of treatment, so he will receive the regimen circled


Contact Screening (1)Contact Screening (1)

• This section records the number of people that the TB patient thinks s/he has come in contact with, along with the number of contacts screened for TB

• Record the number of people that the TB patient thinks they have come in contact with in the first column

• Of these people, record the number of contacts that have been screened using the BNTP screening form


Contact Screening (2)Contact Screening (2)

Example: • Francis Mulenga thinks

he came in contact with 5 people

• Of these, 3 people have been screened for TB


Chest X-Ray (1)Chest X-Ray (1)

• Record results for up to two chest x-rays, along with the date of the chest x-ray

How to fill in this section: • Record the chest x-ray number in the first

section• Draw any abnormalities in the corresponding

location on the picture of the lungs• Using the format “dd/mm/yy,” record the date

in the appropriate column


Chest X-Ray (2)Chest X-Ray (2)

• Example: A patient has a cavity in the right upper lobe, according to his chest x-ray from 25 December, 2004, x-ray number 2234. This section would be completed as shown below


Culture and Sensitivity Report (1)Culture and Sensitivity Report (1)

• All re-treatment cases should submit a sputum specimen for culture and drug sensitivity testing

• If a culture was performed, this section can be used to record the results of the drug sensitivity profile for each TB patient, along with the date


Culture and Sensitivity Report (2)Culture and Sensitivity Report (2)

How to fill in this section: • Using the format “dd/mm/yy”, record the date in the

appropriate column• If the sample is sensitive to a drug, mark the “Sensitive”

column with an “X”• If the patient is resistant to a drug, mark the “Resistant”

column with an “X”Example: • A culture was performed for

a patient on 30 March, 2005• Result showed sensitivity

to all first-line drugs


Treatment Outcome (1)Treatment Outcome (1)

• Categorise the outcome of each TB patient at the end of treatment

• How to fill in this section: Fill in the column with the appropriate outcome:• Cured• Treatment completed• Treatment failure• Died• Defaulted/interrupted• Transferred out


Treatment Outcome (2)Treatment Outcome (2)

Example: • Francis Mulenga was

initially smear-positive, but converted to smear-negative after two months of treatment

• He had a smear-negative sputum result at 6 months.

• Therefore he is considered cured; make an “X” over the box for cured


RemarksRemarks

• This section records specific information not captured by any of the other sections about each TB patient

• How to fill in this section: Following are examples of what can be written in this section:• “Patient’s wife is HIV positive”• “CD4 count = 50 on 12/03/05”

• Example: Francis Mulenga’s wife is HIV-infected; record this information in the remarks section. This remark should also be a reminder that Francis should be offered another HIV test during his treatment


Preparing a TB Preparing a TB Treatment Card ReviewTreatment Card Review

• Were there any sections that were difficult to understand and fill out?

• Do you have any other questions or concerns about the TB Treatment Card?


Key PointsKey Points

• Several approaches are used to monitor and evaluate the TB programme including, supervision, staff meetings, records and registers

• Reporting and record keeping is important to the DOTS strategy

• Good record keeping is vital to measuring success and motivating staff

Documents

Unit 12: Reporting & Recording Botswana National Tuberculosis Programme Manual Training for Medical Officers