HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 1

MINISTRY OF HEALTH

(HMIS Form 105)

Health Unit (HMIS Form Monthly
Outpatient 105) Report
Health Unit Outpatient Monthly Report

Health Unit Name: ………………………………... Level: …………CODE………...

Health Unit Name: .................................................... Level: ..............CODE..................
District/HSD Name…………………………………………………..........................
HSD:..................................................................................................................................

Financial Year: …………………………………………………………........................

District:.............................................................................................................................

Financial Year: ................................................................................................................

Print Version September 2019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT

DESCRIPTION AND INSTRUCTIONS

Objective: To report the monthly data for OPD attendances, diagnoses, MCH, HIV/AIDS service,
Laboratory, stock status of essential drugs and supplies and finances, among others.

Timing: 7th day of the following month

Copies: This report form is in triplicate. The original (white) copy is sent to the District; the
duplicate (pink) copy is sent to the HSD and the triplicate (yellow) copy is retained by the
Health Facility.

For Regional Referral Hospitals and National Referral Hospitals, the original (white) copy
is sent to the respective district health office/City Authority for KCCA, and the other copies
should be retained by the facility.

Responsibility: Health Unit In-Charge

PROCEDURE:

1. All health units must compile and submit the HEALTH UNIT OUT-PATIENT MONTHLY
REPORT (HMIS 105). The health unit is required to compile the type of report by origin of the
population its serves e.g Refugee hosting district they will report a report type for Nationals and for
refugees respectively.

Page 1 - 9 contains:
Section 1 with three sub-sections (1.1-OPD ATTENDANCES, 1.2-REFERRALS AND
1.3-OUTPATIENT DIAGNOSES). The values are obtained from tables 1a, 1b, 1c, 1d and 1e (Health
Unit Outpatient daily diagnoses). If the district wishes to include additional diseases of local interest,
they may do so under the variable of other diagnoses. The DHMT will be responsible for ensuring
all the health units in the district are aware of the chosen additional diagnoses.

2 Page 10 - 17 contains:
Section 2, shows a summary of Maternal and Child Health Services, it includes sub-sections
(2.1-Antenatal, 2.2-Maternity, 2.3-Postnatal, 2.4-Exposed Infant Diagnosis services, 2.5-Early
retention monitoring for EMTCT women, 2.6-Family Planning and 2.7-Child Health Services. The
values are obtained from Table 2a (Health Unit Daily Maternal Health Attendance Summary), Table
3a (Health Unit EPI Daily Attendance Summary) and Table 4a (Health Unit Daily Family Planning
Summary).

Note: DPT-HepB+Hib vaccine doses wasted = doses accessed – doses administered to

children in a given reporting period (in this case a month) where:
• Doses accessed = (Start of month Balance + Total doses received in a month) – (End of
month balance + Doses given to other Units)
• Doses administered = Total Number of children (under and above 1 year) immunized in a
reporting period

For BCG, children above one year receive twice as many doses of vaccine as the under one year
olds and therefore total number of doses administered = No of children <1yr immunized + No of
children >1yr immunized x 2.
Print Version September 2019
HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 3

Section 3, shows a summary of Hepatitis B diagnosis and vaccination

3. Page 22 -22 contains:

Section 4: HIV/AIDS testing services. Information is obtained from HTS register, MCH registers,
SMC registers and Health Unit B register.

4. Page 23 contains:
Section 5: Safe Male Circumcision. Information is obtained from the Safe Male Circumcision Register.

5. Page 24 – 25 contains
Includes Section 6: Essential Medicines and Health Supplies Stock Status where values are
obtained from the Health Facility Stock Book and Stock Cards.
Sub-Section 7, 8 and 9: shows a summary of outreach activities, Meeting and Support supervision
activities both planned and actual number carried out, this is obtained from the health facility work
plan and outreach records of the Individual units within the health facility.
Note: The storekeeper should also report verbally to the Health Facility In-charge and District/HSD
Authorities whenever the stock levels reach minimum stock level.

6. Page 26 - 29 contains:
Section 10: Includes a summary of laboratory tests. The information is obtained from Table 17a
(Laboratory Tests Daily Summary) and

Section 11: (Financial summary): The information for the financial summary is obtained from
Health Facility Cash Analysis Book.

Section 12: (comments by the health facility in-charge): A copy of the comments should be
written in the health unit’s LOGBOOK.

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 1

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 1

Health Unit:........................................................................ Level:..............................................Code...................

District:.............................................................................. HSD:..........................................................................
Sub county................................................................Reporting Period: Month:.......................... Year:.................
Report Type: National Refugee Foreigner

OPD ATTENDANCES, REFERRALS AND DIAGNOSES TOTALS FOR THE MONTH

1.1 OUTPATIENT ATTENDANCE 1.2 OUTPATIENT REFERRALS
0-28 29 days 5 – 9Yrs 10 – 20Yrs & 0-28 29 days 5 – 9Yrs 10 – 20Yrs &
Category days – 4Yrs 19Yrs above Category days – 4Yrs 19Yrs above
M F M F M F M F M F M F M F M F M F M F
OA01.New OR01.Refer-
attendance rals to unit
OA02. OR02.Refer-
Reattendance rals from unit
1.3 OUTPATIENT DIAGNOSES FOR THE MONTH
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.1 Epidemic-Prone Diseases
EP01a. Suspected fever
EP01. Malaria

EP01b. Malaria Total

EP01c. Malaria confirmed (B/s
and RDT Positive)
EP01d. Malaria cases treated
EP02. Acute Flaccid Paralysis
EP03. Animal Bites (suspected rabies)
EP04. Cholera
EP05. Dysentery
EP06. Guinea Worm
EP07. Measles
EP08. Bacterial Meningitis
EP09. Neonatal tetanus
EP10. Plague
EP11. Yellow Fever
EP12. Other Viral Haemorrhagic
Fevers
EP13. Severe Acute Respiratory
Infection (SARI)
EP14. Adverse Events Serious
Following
Immunization
(AEFI) Non Serious
EP15. Typhoid Fever
EP16. Presumptive MDR TB cases
EP17. Other Emerging infectious
Diseases e.g. Influenza like
illness (ILI), SARS
1.3.2 Other Infectious / Communicable Diseases
CD01. Diarrhoea – Acute
CD02. Diarrhoea –Persistent
CD03. Urethral discharges
CD04. Genital ulcers
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 2
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.2 Other Infectious / Communicable Diseases (Continued)
CD05. Sexually Transmitted Infection
due to Sexual Gender Based
Violence
CD06. Other Sexually Transmitted
Infections
CD07. Urinary Tract Infections (UTI)
CD08. Intestinal Worms
CD09. Haematological Meningitis
CD10. Other types of meningitis
CD11.Cough or cold - No pneumonia
CD12. Pneumonia
CD13. Severe Pneumonia
CD14. Skin Diseases
CD15. Tetanus (over 28 days)
CD16. Sleeping sickness
CD17. Pelvic Inflammatory Disease (PID)
CD18. Brucellosis
1.3.3 Neonatal Diseases
ND01. Neonatal Sepsis (0-7days)
ND02. Neonatal Sepsis (8-28days)
ND03. Neonatal Pneumonia (0-7days)
ND04. Neonatal Pneumonia(8-28days)
ND05. Neonatal Meningitis
ND06. Neonatal Jaundice
ND07. Premature baby (as a Condition
for management)
ND08. Other Neonatal Conditions
1.3.4 Non Communicable Diseases/Conditions
NC01. Sickle Cell Anaemia
NC02. Other types of Anaemia
NC03. Gastro-Intestinal Disorders
(non-Infective)
NC04. Pain Requiring Palliative Care
1.3.5 Oral diseases
OD01. Dental Caries
OD02. Gingivitis
OD03. HIV-Oral lesions
OD04. Oral Cancers
OD05. Other Oral Conditions
1.3.6 ENT conditions
EN01. Otitis media acute and chronic
EN02. Mastoiditis
EN03. Hearing loss
EN04. Rhinitis
EN05. Sinusitis
EN06. Epixtasis
EN07. Adenoid Hypertrophy
EN08. Foreign Body in nose ear and
aero- digestive system
EN09. Infected pre -auricular sinuses
and abscess
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 3
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.6 ENT conditions (Continued)
EN10. Otitis external
EN11. Mastoid abscess
EN12. Vertigo
EN13. Tonsillitis
EN14. Tonsillar hypertrophy
EN15. Tinnitus
EN16. Head and neck cancers
EN17. Other ENT conditions
1.3.7 Eye conditions
EC01. Allergic conjunctivitis
EC02. Bacterial Conjunctivitis
EC03. Ophthalmia neonatorum
EC04. Other Forms of Conjunctivitis
EC05. Corneal Ulcers/ Keratitis
EC06. Un Operable Cataract (>6/60)
EC07. Operable Cataract (< 6/60)
EC08. Refractive errors
EC09. Glaucoma
EC10. Trachoma
EC11. Vitamin A Deficiency
EC12. Ocular trauma and Burns
EC13. Diabetic Retinopathy (All stages)
EC14. Chorioretinal, Macular &
Vitreous Disorders
EC15. Uveitis
EC16. Endophthalmitis
EC17. Corneal scars (Non
trachomatous)
EC18. Tumours
EC19. Strabismus ( All types)
EC20. Ptosis and other lid Disorders
EC21. Squamous Cell Carcinoma of
Conjunctiva
EC22. Retinoblastoma
EC23. Other Malignant Tumours
EC24. Other Benign Tumours/Growths
EC25. Other Eye Disorders
EC26. Blindness
EC27. Other eye conditions
EC28. Spectacles Dispensed
1.3.8 Mental Health
MH01. Anxiety Disorders
MH02. Anxiety Disorders due to gender
based violence
MH03. Unipolar Depressive Disorder
MH04. Bipolar disorder
MH05. Schizophrenia
MH06. Post -Traumatic Stress Disorder
MH07. Epilepsy
MH08. HIV related psychosis
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 4
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.8 Mental Health (Continued)
MH09. Alzheimer’s disease
MH10. HIV related dementia
MH11. Alcohol related Dementia
MH12. Dementia due to stroke
(Diabetes, Hypertension)
MH13. Other form of Dementia
MH14. Other Adult Mental Health
Conditions
MH15. Internet addiction
MH16. Alcohol Use Disorder
MH17. Substance (Drug) use Disorder
MH18. Delirium
MH19. Intellectual disability
MH20. Autism spectrum disorders
1.3.9 Neurological Disorders
NE01. Aphasia or Loss of Language
due to Stroke;
NE02. Dysarthria or Speech Disorder
due to Stroke
NE03. Parkinson’s disease
NE04. Dementia or excessive
forgetfulness due to advanced age,
NE05. Amyotrophic Lateral
Sclerosis(ALS)
NE06. Speech disorders due to Head
Injuries(penetrating or closed)
NE07. Persons in Coma / Emergency Care
NE08. Alzheimer Disease
NE09. Down Syndrome (DS)
NE10. CP / PMLD
NE11. Child abuse and Neglect
NE12. Attention Deficit Hyperactivity
disorder (ADHD)
NE13. Learning Disability
NE14. Conduct disorders
NE15. Eating disorders (anorexia,
Bulimia, other feeding)
NE16. Somatoform disorders
NE17. Sleeping Disorders
NE18. Enuresis/Encopresis
NE19. Other Childhood Mental
Disorders
NE20. Mental illness due other Medical/
surgical conditions
NE21. Attempted Suicide/Self-harm
1.3.10 Chronic respiratory diseases
CR01. Asthma
CR02. Chronic Obstructive Pulmonary
Disease (COPD)
1.3.11 Cancers
CA01. Cervical Cancer
CA02. Prostate Cancer
CA03. Breast Cancer
CA04. Lung Cancer
CA05. Liver Cancer
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 5
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.11 Cancers (Continued)
CA06. Colon Cancer
CA07. Kaposis Sarcoma
CA08. Other Cancers
1.3.12 Physiotherapy
PT01. Muscular disorders.
PT02. Joint dysfunction.
PT03. Soft tissue injuries.
PT04. Chronic respiratory diseases.
PT05. Chest trauma/Injury.
PT06. Paralysis due to spinal cord
injury and other diseases
PT07. Cerebral Palsy/Delayed motor
or sensory developmental milestones.(CP)
PT08. Upper Motor Neuron lesions (UMN)
PT09. Facial palsy
PT10. Lower motor neuron lesions
(LMN)
PT11. Gynaecological, obstetric and
urogenital conditions
PT12. Amputee
PT13. Altered Posture and gait.
PT14. Injection neuritis/Acute flaccid
paralysis
PT15. Congenital abnormalities
PT16. Spine disorders e.g neck, thoracic,
lumber, coccygeal pains
PT17. Lymph oedema.
PT18. Patients prescribed with
assistive devices
PT19. Others
1.3.13 Occupational therapy conditions
OT01.Neuro-developmental Disorders
OT02.Sensory Integration disorders
OT03.Adult Neurological Disorders
OT04.Burn injuries
OT05.Post-burns contractures
OT06.Orthopaedic Conditions
OT07. Mental Health Conditions
OT08.Birth Defects and Trauma
OT09. Arthrogryposis
OT10. HIV/ AIDS
OT11. Diabetes
OT12. Cancer
OT13. Other chronic conditions
OT14.Cardiac Conditions
OT15. Patients prescribed with
assistive devices
1.3.14 Speech and Language Therapy
SL01. Speech and language delay/
disorder
SL02. Motor speech disorders
SL03. Hearing impairments
SL04. Voice disorders

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 6
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.14 Speech and Language Therapy (Continued)
SL05. Dysfluency /stammering
SL06. Acquired neurological disorders
SL07. Cleft lip and palate
SL08. Others
1.3.15 Disabilities
DS01.Individuals with Difficulty in seeing
DS02.Individuals with Albinism
DS03.Individuals with Difficulty in hearing
DS04.Individuals with Speech Difficulties
DS05.Individuals with delayed age
specific motor development
DS06.Individuals with Dwarfism
DS07.Individuals with Difficulty
understanding
DS08.Individuals with Difficulty in
remembering
DS09.Individuals with Difficulty in reading
DS10.Individuals with Difficulty in writing
DS11.Individuals with Difficulty in self-care
DS12.Individuals with Mentally
impairment
DS13. Individuals with Emotionally
impairment
1. 1.3.16 Cardiovascular diseases
CV01. Stroke/ Cardiovascular
Accident(CVA)
CV02. Hypertension
CV03. Heart failure
CV04. Ischemic Heart Diseases
CV05. Rheumatic Heart Diseases
CV06. Chronic Heart Diseases
CV07. Other Cardiovascular Diseases
1.3.17 Endocrine and Metabolic Disorders
EM01. Diabetes mellitus
EM02. Thyroid Disease
EM03. Other Endocrine and Metabolic
Diseases
1.3.18 Injuries
IN01. Jaw injuries
IN02a. Motor Vehicle
IN02.Road IN02b. Motor Cycle
Traffic
Injuries IN02c. Bicycles
IN02d. Others
IN03. Injuries due to Gender based
violence
IN04. Injuries (Trauma due to other
causes)
IN05. Animal IN05a. Domestic
bites IN05b. Wild
IN06. Snake bites
IN07. Insect bites
1.3.19 Minor Operations in OPD
MN01. Tooth extractions
MN02. Dental Fillings
MN03. Other Minor Operations
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 7
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.20 Neglected Tropical Diseases (NTDs)
NT01. Leishmaniasis
NT02. Lymphatic Filariasis (hydrocele)
NT03. Lymphatic Filariasis
(Lympoedema)
NT04. Urinary Schistosomiasis
NT05. Intestinal Schistosomiasis
NT06. Onchocerciasis
1.3.21 Maternal conditions
MC01. Abortions due to Gender-Based
Violence (GBV)
MC02. Abortions due to other causes
MC03. Number of Post Abortion women
who received FP
MC04. Malaria in pregnancy
MC05. High blood pressure in pregnancy
pressure in pregnancy
MC06. Obstructed labour
MC07. Puerperal sepsis
MC08. Haemorrhage related to
pregnancy (APH)
MC09. Haemorrhage related to
pregnancy (PPH)
Total Screened
MC10. Breast
cancer Number with breast
cancer
Total Screened
MC11. Cervical
cancer Number with cervical
cancer
1.3.22 Other OPD conditions
OP01. All others
Disease code1
OP02. Other diagnoses
(specify priority Disease code2
diseases for District)
Disease code3
DT01. Deaths in OPD
1.3.23 Risky Behaviours
RB01. Alcohol use
RB02. Tobacco use
RB03. Tobacco exposure
1.3.24 Emergency Medical Services
ES01. Number of emergency cases at
the facility
ES02. Patients that receive care at the
scene of emergency
ES03. Emergency cases that arrive at
the facility using an Ambulance
ES04. Number of patients assessed
for level of consciousness using
GCS/ other comma score
ES05. Number of patients accessing care
within 1hr in an emergency unit
ES06. Number of patients who develop
complications within 24 hours
after management/care
ES07. Number of patients with hypoxemia
administered with oxygen
ES08. Number of patients with external
haemorrhages controlled

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 8
0-28 days 29 days - 4Yrs 5 – 9Yrs 10 – 19Yrs 20Yrs & above
Diagnosis
Male Female Male Female Male Female Male Female Male Female
1.3.24 Emergency Medical Services (Continued)
ES09a. Medical
emergencies
ES09b. Obstetrics
gynaecology
emergencies
ES09. ES09c. Paediatric
Number of emergencies
death at
emergency ES09d. Surgical
unit emergencies
ES09e. Road traffic
Injuries
ES09f. Burns
ES09g. Poisoning
ES10. Total number of Death in
Emergency Unit
ES11. Number of ES11a.Tetanus
Patients ES11b. Rabies
receiving
vaccination for ES11c. Others
1.4 Tuberculosis and Leprosy services
<5 years 5 - 9years 10-14 years 15-19 years 20+ years
Male Female Male Female Male Female Male Female Male Female
TB Screening in OPD
TP01. Number screened for TB in OPD
TP02. Number of presumptive TB cases identified
from OPD
TP03. Number of presumptive cases diagnosed
with TB from OPD
Registration in TB Treatment Unit
TP04. Total New and relapse TB cases registered
in TB treatment unit
TB Preventive Therapy (TPT)
TP05. Number of contacts of TB patients started
on TPT
TP06. Number of ART clients started on TPT
Leprosy services
TP07. New and relapse PB (Paucibacillary)
leprosy cases registered MB (MultiBacillary)
1.5 Nutrition Services
0-5 6-23 24-59 5-9 10-19 20-24 25+
Data Elements Months Months Months Years Years Years Years
M F M F M F M F M F M F M F
Pregnant /

Pregnant /

Pregnant /
Pregnant

Lactating

Pregnant

Lactating

Pregnant

Lactating
Non

Non

Non

NA01a. MUAC Tape

NA01. No. of clients
who received NA01b. W/H or L Z-Score
nutrition assessment in
this month NA01c. BMI for Age
using; Z-Score
NA01e. Body Mass
Index (BMI)
NA02. No. of children that are underweight (W/A
≤-2 SD)
NA03. No. of NA03a. MAM using MUAC:
identified MUAC: ≥ 11.5cm & < 12.5cm
malnourished (children 0-59 mths)
clients
this month; MUAC: ≥ 19.0cm & <23.0cm
(PLW 10-25+ yrs)

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 9
M F M F M F M F M F M F M F

/Lactating

/Lactating

/Lactating
Pregnant
Pregnant

Pregnant
Pregnant

Pregnant
Pregnant
Non

Non

Non
1.5 Nutrition Services (Continued)
NA03b. MAM using W/H or L
W/H or L: ≥ -3 SD & < -2 SD
NA03c. SAM using MUAC
MUAC: < 11.5cm (children
0-59 mths) MUAC: <19.0cm
(PLW 10-25+ yrs)
NA03d. SAM using W/H or L
W/H or L: < -3 SD
NA03. No. of NA03e. SAM With Oedema
identified NA03f. Moderately
malnourished Malnourished
clients
this month; (5-9yrs & 10-19yrs: <- 2SD & ≥-3SD;
>19yrs: ≥16.0 & ≤16.9)
NA03g. Severely Malnourished
(5-9yr & 10-19 yrs: <
-3SD;>19yrs: < 16.0)
NA03h. Overweight (5-9yrs:
>+1SD & ≤+3SD; >19yrs:
≥25.0 & ≤29.9)
NA03i. Obese (5-9yrs & 10-
19yrs: <+ 2SD; >19yrs: ≥ 30.0)
NA04. No. of SAM NA04a. Total
admissions in
OTC this month; NA04b. New Admissions
NA05. No. of NA05a. Relapses
Readmissions into
OTC this month; NA05b. Defaulters
NA06. No. of MAM NA06a. Total
admissions in
Supplementary
Feeding Care (SFC); NA06b. New Admissions
NA07. No. of NA07a. Relapses
Readmissions in
SFC this Month NA07b. Defaulters
NA08a. Discharged as cured
within this month
NA08. No. of NA08b. Did not respond to care
clients in OTC (non-response) after 3
with SAM months of treatment
admitted into NA08c. Defaulted from care
treatment and within this month (absent for 2
consecutive visits)
NA08d. Died during treatment
within this month
NA09. Total number of days spent in OTC for all
clients discharged as cured this month
NA10a.Discharged as cured within this month
NA10. No.
of clients NA10b. Did not respond to care in
with MAM SFC (non-response) after 3 months of
admitted treatment
into NA10c. Defaulted from care within this month
treatment (absent for 2 consecutive visits)
and
NA10d. Died during treatment within
this month
NA11. Total number of days spent in SFC for all
clients discharged as cured this month
NA12. No. of malnourished clients who are
positive for TB
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 10
2.0 MATERNAL AND CHILD HEALTH SERVICES 2.1 ANTENATAL (Continued) NUMBER
2.1 ANTENATAL NUMBER Below 15 years
Below 15 years 15-19 years
15-19 years AN11. IPT 4 & 4+ Dose 20-24 years
AN01.ANC 1st contacts/ Total 20-24 years 25-49 years
visits for women 25-49 years 50+ years
50+ years Screened for TB
AN12. TB Screening for
No. in 1st Trimester ANC clients Presumed to have TB
Below 15 years Diagnosed with TB
15-19 years Total
AN13. Blood & Rhesus group (O)
AN02.ANC 4th contacts/ 20-24 years Rhesus O+
visits for women
25-49 years Total
AN14. Blood & Rhesus group (A)
50+ years Rhesus A+
Total
Below 15 years AN15. Blood & Rhesus group (B)
Rhesus B+
15-19 years
AN03. ANC 4+ contacts/ AN16. Blood & Rhesus group Total
20-24 years
visits for Women (AB) Rhesus AB+
25-49 years
AN17.No. of pregnant women who were tested for
50+ years Anaemia using Hb Test at ANC 1st Contact / visit
Below 15 years AN18. No. of pregnant women with Anaemia
(Hb <10g/dl) at ANC 1st Contact / visit
15-19 years
AN04. ANC 8 contacts/ AN19. No. of pregnant women who were tested for
20-24 years anaemia using Hb test at ANC after 36 weeks
visits for Women
AN20. No. of pregnant women with Anaemia
25-49 years
(Hb <10g/dl) at ANC after 36 weeks
50+ years AN21. Pregnant Women receiving at least 30 tablets of
Below 15 years Folic Acid and Iron Sulphate at ANC 1st contact / visit
(Only Folic Acid recommended during 1st trimester)
15-19 years AN22. Pregnant Women receiving at least 30 tablets
AN05. Total ANC contacts/
visits (new clients + Re- 20-24 years of Folic Acid and Iron Sulphate at ANC after 36
attendances) weeks of gestation
25-49 years
AN23. Pregnant Women receiving LLINs at ANC 1st visit
50+ years
AN24. No. of pregnant women Total U/S Scan done
AN06. Referrals to ANC Total referrals who received obstetric-ultra No. done before 24
unit sound scan during any ANC weeks of gestation
From community services visit in the reporting month and below
Total referrals AN25. No. of pregnant women Total
AN07. ANC Referrals from
unit HIV+ mothers newly dewormed or receiving After 28 weeks of
enrolled in MCH groups mebendazole gestation
Below 15 years AN26. Pregnant Women No. Tested
15-19 years tested for syphilis for the first No. Tested Positive
time in this pregnancy
AN08. First dose IPT No. started on
20-24 years syphilis treatment
(IPT1)
25-49 years No. Tested
50+ years AN27. Male partners tested for No. Tested Positive
syphilis
Below 15 years No. started on
syphilis treatment
15-19 years No. Tested
AN09. Second dose IPT AN28. Pregnant women tested No. Tested Positive
20-24 years
(IPT2) for Hepatitis B.
25-49 years No. started on Hep
B treatment
50+ years Total Number ANC1
Below 15 years AN29. Pregnant Below 15 years Number ANC1
15-19 years women newly 15-19 years Number ANC1
AN10.Third dose IPT tested for HIV in
20-24 years 20-24 years Number ANC1
(IPT3) this pregnancy at
25-49 years any ANC visit (TR 25-49 years Number ANC1
50+ years & TRR) 50+ years Number ANC1
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 11
2.1 ANTENATAL (Continued) NUMBER 2.1 ANTENATAL (Continued) NUMBER
Total Total ART-K during the month
Number ANC1

25-49 years
Below 15 years Number ANC1 Viral Load Samples
AN30. Pregnant collected during the month
15-19 years Number ANC1
Women tested HIV+ Viral Load results Returned
for 1st time this preg- 20-24 years Number ANC1 AN34.HIV+ during the month
nancy (TRR) at any pregnant
25-49 years Number ANC1 women already Viral Load Suppressed
ANC Visit during the month
50+ years Number ANC1 on ART before
1st ANC (ART-K) Total ART-K during the month
Below 15 years Number ANC1 (Continued) Viral Load Samples

50+ years
15-19 years Number ANC1 collected during the month
AN31. HIV+ Pregnant Viral Load results
women assessed by 20-24 years Number ANC1 Returned during the month
CD4 Viral Load Suppressed
25-49 years Number ANC1 during the month
50+ years Number ANC1 AN35. Pregnant women Total (TR+ &TRR+)
AN32. HIV+ pregnant who re-tested later in
Below 15 years pregnancy HIV+ (TRR+)
women initiated on
ART for eMTCT at 15-19 years AN36. HIV+ pregnant women given ARV prophylaxis for
the un born infants for the 1st time in ANC
Any visit irrespective 20-24 years
of when tested HIV+ AN37. Pregnant Total
(TRR, TRR+ and 25-49 years women given
HIV+ not yet started self-testing kits for Tests returned HIV+
50+ years their male partners Tests returned HIV negative
ART(TRR√ & TRRK))
Total (TRK + TRRK) AN38: Male partners Total tested (TR & TRR)
received HIV test
AN33. Pregnant Below 15 years results in eMTCT HIV+ (TRR).
HIV+ (TRRK)

Women who knew 15-19 years

status before AN39. Male partners Total (TRK & TRRK)
20-24 years with a known status
1st ANC at their first visit as a
25-49 years couple in ANC HIV+ (TRRK)
50+ years AN40. HIV+ Male partners initiated on ART in the ANC
setting
Total ART-K
during the month AN41. Number of discordant couple identified in ANC
AN42.
Viral Load Maternal Nutrition Total
Below 15 years

Samples collected Pregnant

women Counselling HIV+
during the month
who
Viral Load results received Infant Feeding Total
Returned during Counselling Counselling
the month HIV+
Viral Load 2.2 MATERNITY NUMBER
Suppressed
during the month MA01: Admissions
Total ART-K
MA02: Referrals to Total
during the month
maternity unit From community services
Viral Load
AN34.HIV+ pregnant Samples collected
15-19 years

MA03: Maternity referrals out

women already on during the month
ART before 1st ANC Viral Load results Below 15 years
(ART-K) Returned during
15-19 years
the month
Viral Load MA04a. Total 20-24 years
Suppressed
during the month 25-49 years
Total ART-K 50+ years
during the month MA04:
Deliveries in MA04b. Total
Viral Load unit
Samples collected Live births
20-24 years

< 2.5 Kg
during the month
Viral Load results MA04c. Fresh still Total
Returned during birth
the month < 2.5 Kg
Viral Load MA04d. Total
Suppressed Macerated still
during the month birth < 2.5 Kg
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 12
2.2 MATERNITY (continued) 2.2 MATERNITY (Continued) NUMBER
NUMBER Baby
MA27. Number received PNC
Total within 24 hours after birth Mother
MA05. Pre-Term births Alive
Oxytocin
< 2.5 Kg MA28. Uterotonics used in man- Misoprostol
Total agement of 3rd stage of labour
MA06. Born Before Arrival Alive Egometrine
< 2.5 Kg
2.3 POSTNATAL NUMBER
MA07. No. of low birth weight babies (<2.5 Kg)
Below 15 years
initiated on kangaroo (KMC)
MA08. Live babies at discharge 15-19 years
MA09. No. of Babies born with defect Age group 20-24 years
25-49 years
MA10. No. of Babies received LLIN PN01.Post Natal
50+ years
MA11. Newborn deaths (0-7 days) Attendances
24 Hours
MA12. Neonatal Death 8-28 days 6 Days
Timing
Below 15 years 6 Weeks
15-19 years 6 Months
PN02. Referrals to Total referrals
MA13. Maternal deaths 20-24 years
PNC unit From community services
25-49 years PN03. Breast feeding Total (TR & TRR)
50+ years mothers tested for
HIV 1st time during
Postnatal HIV+ (TRR)
MA14. No. of mothers who Total
initiated breastfeeding within PN04.Breastfeedng Total (TR+ & TRR+)
the 1st hour after delivery No. HIV + mothers re-tested for
HIV during Postnatal TRR+
MA15. Women tested for HIV in Total (TR & TRR) Total HIV+
labour 1st time this Pregnancy HIV+ (TRR) PN05. HIV+ women New Positives (TRR)
initiating ART in Positive on re-test (TRR+)
MA16. Women re-tested for Total (TR+ & TRR+) Postnatal
Positives but never initiated in
HIV in labour HIV+ (TRR+) ANC, Labour and Delivery (TRRK)
PN06.HIV+ breastfeeding mothers newly enrolled in
MA17. HIV+ women initiating ART in maternity MCH groups
PN07: Mother-baby pairs enrolled at Mother-Baby care
MA18. Male partners received Total (TR & TRR) point
HIV test results in the
maternity setting HIV+ (TRR) PN08. Male partners Total (TR & TRR)
received HIV
MA19. HIV+ male partners initiated on ART in test results in the
the maternity setting postnatal setting HIV+ (TRR)

MA20. Number of discordant couples identified PN09. HIV+ male partners initiated on ART in the
in maternity postnatal setting
PN10.Breast Total
Maternal Total feeding mothers
Nutritional given self-testing Tests returned HIV+
MA21. Mothers Received HIV+ kits for their male
nutrition Counselling partners Tests returned HIV negative
Infant Total
Feeding PN11. Number of discordant couples identified in PNC
HIV+
Clients screened for Cancer of
Total PN12. Cancer of the Breast
MA22. Deliveries to HIV+
the breast Clients with pre-malignant
women in unit Live births conditions of breast
Clients screened for Cancer of
Total number PN13. Cancer of the Cervix
MA23. HIV Exposed
infants given ARVs Number of high-risk the Cervix Clients with pre-malignant
infants 12 weeks conditions of cervix
MA24. No. of babies with Birth asphyxia PN14. Lactating mothers who received Total
Nutritional assessment HIV+
MA25: No. of Live babies Successfully
Resuscitated Total
PN15. Post- Maternal Nutritional
natal mothers HIV+
MA26. Number received Baby
PNC check at 6 hours who received Total
Counselling Infant Feeding
after birth Mother HIV+

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 13
2.4 EXPOSED INFANT DIAGNOSIS (EID) 2.5 EARLY RETENTION MONITORING FOR EMTCT WOMEN
NUMBER
SERVICES NET
Total NUMBER CURRENT
ED01. Exposed Infants Within 2 Months COHORT*
Tested for HIV below 18 ER01. EMTCT mothers known to be active
months of age by 1st Tested HIV+ on ART treatment 1 month after ART initiation
PCR Tested HIV+ within 2 ER02. EMTCT mothers known to be active on
months ART treatment 2 months after ART initiation
ED02. Exposed Infants Total
Tested for HIV by 2nd ER03. EMTCT mothers known to be active on
PCR Tested HIV+ ART treatment 3 months after ART initiation
ED03. Exposed Infants Total *Net current Cohort=Original Cohort + Transfer In – Transfer Out
Tested for HIV by 3rd
PCR Tested HIV+ NEW
2.6 FAMILY PLANNING METHODS REVISITS
Total USERS
ED04. 1st DNA/PCR Results returned within 2 Below 15 years
results returned weeks 15-19 years
Results given to caregiver FP01.Oral:
Lo-Femenal 20-24 years
Total
25-49 years
ED05. 2nd DNA/PCR Results returned within 2
results returned weeks 50+ years
Results given to caregiver Below 15 years
ED06. DNA/PCR 6 Total 15-19 years
weeks after cessation Results returned within 2 FP02. Oral:
of breastfeeding results weeks 20-24 years
Microgynon
returned Results given to caregiver 25-49 years
ED07.HIV exposed infants given ARV prophylaxis for the 50+ years
first time at mother baby care point
Below 15 years
ED08. Number of HIV+ Total
infants from EID enrolled 15-19 years
on ART Within 2 Months FP03. Oral: Ovrette or 20-24 years
Total another POP
ED09. HIV exposed 25-49 years
started on CPT Within 2 Months
50+ years
2.4.1 OUTCOMES OF HIV EXPOSED INFANTS NUMBER Below 15 years
REGISTERED 24 MONTHS AGO
OE01.Total number of HEIs registered in the birth cohort 15-19 years
OE02. HEIs that initiated ARV prophylaxis for FP04. Oral: 20-24 years
eMTCT between 0-6 weeks in the cohort Levonogesteral
OE03. HEIs that received ARV prophylaxis for 12 25-49 years
weeks (High risk infants) in the cohort 50+ years
OE04. HEIs that received CTX prophylaxis at the
age within 2 months in the cohort Below 15 years
OE05. HEIs that had a 1st DNA/PCR done within 15-19 years
2 months
FP05. Oral: Others 20-24 years
OE06. HEIs that had a 2nd DNA/PCR at 9 months
of age 25-49 years
OE07. HEIs that had DNA/PCR done at 6 weeks 50+ years
after cessation of breastfeeding
OE08. Number of HIV exposed infants exclusively Below 15 years
breastfed for the first 6 completed months during 15-19 years
the reporting period FP06. Injectable
OE09. Number of HIV exposed infants who were DMPA(IM e.g Depo)3 20-24 years
reported to be breastfed up-to 1 year months
25-49 years
2.4.2 FINAL TEST RESULTS –HEI Outcomes at 50+ years
NUMBER
24 months.
OE10.Number of HIV exposed Total Below 15 years
infants tested HIV positive on 15-19 years
any DNA/PCR or rapid test Initiated on ART FP07.Injectable
DMPA(SC e.g Sayana 20-24 years
OE11.Number of HIV exposed infants who died press) 3 months
before 18 months of age 25-49 years
OE12.Number of HIV exposed infants transferred 50+ years
out before 18 months of age
Below 15 years
OE13.Number of HIV exposed infants were lost to
follow up before 18 months of age 15-19 years
FP08. Injection 2
OE14. Number of HIV exposed infants who were 20-24 years
months
discharged HIV negative on final rapid test 25-49 years
OE15.Number of HEIs whose final HIV status is
unknown (include in care but no test done) 50+ years
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 14
NEW NEW
2.6 FAMILY PLANNING METHODS REVISITS 2.6 FAMILY PLANNING METHODS REVISITS
USERS USERS
Below 15 years Below 15 years
15-19 years FP19. Female 15-19 years
FP09. Injection 1 condoms
20-24 years 20-24 years
month
25-49 years 25-49 years
50+ years 50+ years
Below 15 years Below 15 years
15-19 years 15-19 years
FP10. 3 year implant
(e.g. implananon NXT, 20-24 years FP20. Male condoms 20-24 years
Levo plant) 25-49 years
25-49 years
50+ years 50+ years

Below 15 years

PHARMACIES/
DRUG SHOPS
NO. DISP. BY
NO. DISP. AT

NO. DISP. BY
NO. DISP. IN
OUTREACH
15-19 years 2.6.1 CONTRACEPTIVES
DISPENSED
FP11. 4 year implant 20-24 years

CBDs
UNIT
(e.g. Sino plant)
25-49 years
50+ years CT01. Oral: Lo-Femenal (cycles)
Below 15 years CT02. Oral: Microgynon (cycles)
15-19 years CT03. Oral: Ovrette or other POP (cycles)
FP12. 5 year implant 20-24 years CT04. Oral: Levonogesteral (cycles)
(e.g. Jadella)
25-49 years CT05. Oral: Emergency
contraceptives
50+ years
CT06. Oral: Others (cycles)
Below 15 years
15-19 years CT07. Female condoms (pieces)
FP13. IUD-Copper-T 20-24 years CT08. Male condoms (pieces)
25-49 years CT09: Injectable 3 months IM (doses)
50+ years CT10. Injectable 3 months SC (doses)
Below 15 years CT11. Injectable 2 months (doses)
15-19 years CT12. Injectable 1 month (doses)
FP14. IUD-Hormonal 20-24 years CT13. FAM-SDM (Cycle beads)
25-49 years (pieces)
50+ years CT14. IUDs–Copper T
Below 15 years CT15. IUDs –Hormonal
CT16. 3 year implant (e.g impalanon
15-19 years NXT, Levo plant)
FP15. FAM-SDM 20-24 years
method CT17. 4 year implant (e.g Sino plant)
25-49 years CT18. 5 year implant (e.g Jadella)
50+ years
2.6.2 MINOR OPERATIONS IN FAMILY PLANNING
Below 15 years
Below 15 years
15-19 years
FP16. FAM-LAM 20-24 years 15-19 years
25-49 years Timing 20-24 years
50+ years PFH01. No of 25-49 years
Below 15 years Mothers who
received family 50+ years
15-19 years
FP17. FAM-Two Days 20-24 years planning in Below 15 years
Method Postpartum by
25-49 years 15-19 years
50+ years Method 20-24 years
Below 15 years 25-49 years
15-19 years
FP18. Emergency 50+ years
Contraceptive Pills 20-24 years
users MF03-Implant removals
25-49 years
50+ years MF04-IUD removals
Print Version September 2019
 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 15
2.6.3 INTEGRATED SERVICES IN FAMILY PLANNING 2.6.4 POST PERTERM FAMILY PLANNING
Data Element NUMBER Less Than 48 hours
FH01. Number HIV+ FP Users 48hrs to 3 weeks
FH02. Number of FP Users screened for Cervical Cancer Timing 4weeks to 5weeks
FH03. STI screening in Total screened PFH01. No of 6 weeks to 5 months
Family planning Mothers who
Positive 6 months to 12 months
received family
planning in Oral formulation
Postpartum by
Injectable
Method implants
IUDs
Sterilization

2.7 CHILD HEALTH SERVICES

6 – 11 Months 12 – 59 Months 5 – 14 Years
Male Female Male Female Male Female
Static
CH01- Vit A supplement
(1st dose) Outreach
In school
Static
CH02- Vit A supplement
(2nd dose) Outreach
In school
Static
CH03- Dewormed
(1st dose) Outreach
In school
Static
CH04- Dewormed
(2nd dose) Outreach
In school
2.7.1 HPV VACCINATION
Facility School Community
Vaccination of only 10 years OLD girls
(F) (S) (C)
VP01. HPV1-Dose 1
VP02.HPV2-Dose 2

2.7.2 TETANUS VACCINATION (Td VACCINE)

Doses Pregnant women Non-pregnant women
Immunization
Static Outreach Static Outreach
in School
TD01. Td1-Dose 1
TD02. Td2-Dose 2
TD03. Td3-Dose 3
TD04. Td4-Dose 4
TD05. Td5-Dose 5

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 16
2.7.3 CHILD IMMUNISATION
Under 1 1-4 Years 5 – 14 Years
Doses
Static Outreach Static Outreach Static Outreach
CL01. BCG
CL02. Protection At Birth for Td(PAB)
CL03. Polio 0
CL04. Polio 1
CL05. Polio 2
CL06. Polio 3
CL07. IPV
CL08. DPT-HepB+Hib 1
CL09. DPT-HepB+Hib 2
CL10. DPT-HepB+Hib 3
CL11. PCV 1
CL12. PCV 2
CL13. PCV 3
CL14. Rotavirus 1 Vaccine
CL15. Rotavirus 2 Vaccine
CL16. Measles (MR1)
CL17. Measles 2 (MR2)
CL18. Fully immunized by 1 year
CL19. Number received LLIN

2.7.4 VACCINE AVAILABILITY AND WASTAGE

Doses wasted
Open Balance Received Closing
Antigen Doses in Closed Doses in Open
(A) (B) Balance (C)
Vials (CV) Vials (OV)
WT01. BCG
WT02. Polio (OPV)
WT03. IPV
WT04. DPT+HepB+Hib
WT05. PCV
WT06. Rotavirus
WT07. Measles
WT08. Td
WT09. HPV
WT10. Yellow Fever
2.7.5 COLD CHAIN MONITORING
CC01. Number of high temperature alarms
CC02. Number of low temperature alarms
CC03. Number of cold chain refrigerators available
CC04. Number of cold chain refrigerators that are functional

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 17
2.7.6 EPI/EID/PMTCT Integration TOTAL
PI01. Number of Infants screened for HIV-exposure at DPT1, 2, 3 and Measles immunization during month
PI02. Number of HIV-exposed infants identified at immunisation during the month
PI03. Number of HIV-exposed infants tested during immunisation during the month
Total (TR & TRR)
PI04. Number of breastfeeding women tested for HIV for the first time at immunization
TRR
Total (TRK & TRRK)
PI05. Number of breastfeeding women with a known HIV status at immunization
TRRK
Total (TR+ & TRR+)
PI06. Number of breastfeeding women re-tested for HIV at immunization
TRR+
PI07. Number of HIV+ breastfeeding women identified at immunization initiating ART

3.0 HEPATITIS
<10yrs 10-19yrs 20-59yrs 60+ years
M F M F M F M F
HB01. Number of clients tested for HepB

HB02. Number tested negative for HepB

1st Dose (New)

HB03. Number tested negative for 2nd Dose(Revisit)
HepB and Vaccinated
3rd Dose(Revisit)
HB04. Number tested positive for HepB

HB05. Number tested positive for HepB and enrolled for treatment

HB06. Number tested positive for HepB and not enrolled into care and treatment

HB07. Number of persons assessed for HepB treatment effectiveness

(viral load suppression)
HB08. Number of persons with HepB effective treatment (viral load suppression)

HB09. Number of pregnant women tested for HepB (Subset of row 1)

HB10. Number of pregnant women tested positive for HepB (Subset of row 4)

HB11. Number of pregnant women tested positive for HepB and

initiated on HepB treatment (Subset of row 5)
HB12. Number tested for HepC

HB13. Number tested positive for HepC (Anti-HCV)

HB14. Number confirmed positive for HepC (HCV RNA)

HB15. Number tested positive for HCV RNA and enrolled for treatment

HB16. Number of persons assessed for HepC Sustained Viral response

Print Version September 2019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 18
4.0 HIV/AIDS TESTING SERVICES (HTS)
Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of
individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals
Below 1yr 1–4 5-9 10 – 14 15 - 19 20 – 24 25 - 29 30 - 34 35 – 39 40 – 44 45 – 49 50+
M F M F M F M F M F M F M F M F M F M F M F M F
Tested for HIV
Ward/IPD New HIV positive
Linked to HIV care
Tested for HIV
OPD New HIV positive
Linked to HIV care
Tested for HIV
ART Clinic New HIV positive
Linked to HIV care
Tested for HIV
TB Clinic New HIV positive
Linked to HIV care
(by Entry Point for Health facility testing)

Tested for HIV

HT01. Number of individuals

Nutrition
New HIV positive
Unit
Linked to HIV care
Tested for HIV
STI Clinic New HIV positive
Linked to HIV care
Tested for HIV
Young
Child New HIV positive
Clinic
Linked to HIV care
Tested for HIV
ANC New HIV positive
Linked to HIV care
Tested for HIV
Maternity New HIV positive
Linked to HIV care
Tested for HIV
PNC New HIV positive
Linked to HIV care
Tested for HIV
Family New HIV positive
Planning
Linked to HIV care

Print Version September 20019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 19

Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of
individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals
Below 1yr 1–4 5-9 10 – 14 15 - 19 20 – 24 25 - 29 30 - 34 35 – 39 40 – 44 45 – 49 50+
M F M F M F M F M F M F M F M F M F M F M F M F
Tested for HIV
(by Entry Point for Health facility
HT01. Number of individuals

SMC New HIV positive

Linked to HIV care
Tested for HIV
testing)

EID New HIV positive

Linked to HIV care

Other Tested for HIV

Facility New HIV positive
Based
Points Linked to HIV care
Tested for HIV
Work
New HIV positive
place
HT02 Number of individuals (by Entry Point for

Linked to HIV care

Tested for HIV
Home-
Based New HIV positive
Testing
Community testing)

Linked to HIV care

Tested for HIV
Drop in
New HIV positive
centre
Linked to HIV care
Tested for HIV
Hotspots New HIV positive
Linked to HIV care
Tested for HIV
Other
Community New HIV positive
Testing
Linked to HIV care
Tested for HIV
HT03. Total
number of New HIV positive
Individuals
Linked to HIV care
Tested for HIV
Health
individuals (by PITC
HT04. Number of
Testing approach)

New HIV positive

Facility
Linked to HIV care
Tested for HIV
Community New HIV positive
Linked to HIV care

Print Version September 20019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 20
Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of
individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals
Below 1yr 1–4 5-9 10 – 14 15 - 19 20 – 24 25 - 29 30 - 34 35 – 39 40 – 44 45 – 49 50+
M F M F M F M F M F M F M F M F M F M F M F M F
Tested for HIV
individuals(by CICT/VICT

Health
New HIV positive
HT05. Number of
Testing approach

Facility
Linked to HIV care
Tested for HIV
Community New HIV positive
Linked to HIV care
HT06. Number of Individuals who received
HIV test results
HT07. Number of individuals tested for the first
time ever
HT08-Total Number of Individuals who tested
HIV positive (New + Known)
HT09 Number of newly Long-term infection
diagnosed HIV positive
individuals with a test
for recent infection result Recent infection
HT10. HIV positive individuals with
presumptive TB
HT11. Number of Individuals tested more than
once in the last 12 months
HT12. Number of individuals who were
Counselled and Tested together as a Couple
HT13. Number of individuals who were Tested
and Received results together as a Couple
HT14. Number of individuals with Concordant
positive results who tested as Couples
HT15. Number of individual with Discordant
results who tested as Couples

HT16. Individuals counselled and tested for PEP

HT17. Number of individuals tested as Special
Categories
Tested for HIV
HT18. Number of individuals

Prisoners Tested HIV Positive

Linked to HIV Care
Tested for HIV
People Who
Tested HIV Positive
Inject Drugs
Linked to HIV Care
Tested for HIV
Uniformed
Tested HIV Positive
men
Linked to HIV Care

Print Version September 20019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 21

Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of
individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals
Below 1yr 1–4 5-9 10 – 14 15 - 19 20 – 24 25 - 29 30 - 34 35 – 39 40 – 44 45 – 49 50+
M F M F M F M F M F M F M F M F M F M F M F M F

Tested for HIV

Migrant
Tested HIV Positive
Workers
Linked to HIV Care

Tested for HIV

Truckers Tested HIV Positive

Linked to HIV Care

Tested for HIV

Fisher Folk Tested HIV Positive

Linked to HIV Care

Tested for HIV

Refuges Tested HIV Positive

HT18. Number of individuals

Linked to HIV Care

Tested for HIV

Pregnant
Tested HIV Positive
women
Linked to HIV Care

Tested for HIV

Breast feeding
Tested HIV Positive
women
Linked to HIV Care

Adolescent Tested for HIV

Girls and
Tested HIV Positive
Young Women
(AGYW) Linked to HIV Care

Tested for HIV

People with
Disabilities Tested HIV Positive
(PWD)
Linked to HIV Care

Tested for HIV

Others Tested HIV Positive

Linked to HIV Care

Print Version September 20019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 22
Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of Number of
individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals
Below 1yr 1–4 5-9 10 – 14 15 - 19 20 – 24 25 - 29 30 - 34 35 – 39 40 – 44 45 – 49 50+
M F M F M F M F M F M F M F M F M F M F M F M F
HT19. Number Elicited
of partners
Notified

HT20. Number Total

of partners
APN tested HIV Positive

HT21. Number Already in HIV care

of HIV-positive
partners Linked to HIV care/
ART

HT22. Number Directly Assisted

of HIV Self -Test
kits distributed by
model Unassisted
HIVST
HT23. Number of individuals who
report a Positive HIV Self-Test
HT24. Number of individuals with
confirmed positive results with the
National algorithm

Print Version September 20019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 23
5.0 SAFE MALE CIRCUMCISION (SMC)
>2mth­ 1–9 10 – 14 15 – 19 20 – 24 25 – 29 30 – 34 35 – 39 40 – 44 45-49 50+
Category Age Group 0-60 days <1yr Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Total

+VE

-VE
SM01. Number of Males
Counselled and Tested for HIV at INC
SMC site
Known +VE

Not Tested

SC
SM02. Number of Males Facility
Circumcised (by Age Group- DC
Years) and Technique (SC
- Surgical SMC, DC - Device- SC
Based SMC) Outreach
DC

Facility Outreach
Technique
SC DC SC DC

Within 48 hours(0-48)
SM04. Number of males Circumcised who Returned for Follow Up
Within 7 days (>0-7)

Within 14 days (>0-14)

Beyond 14 days

SM05. Number of males Circumcised who Experienced one or more Adverse Events Moderate
(Report only Moderate or Severe AEs) Severe

NUMBER

Managed by the site

SM06. Number of circumcised males with Adverse Events
Referred

SM07. Number of clients who received Td First dose (Td1)

Second dose (Td2)

Print Version September 20019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 24
6.0 ESSENTIAL MEDICINES AND HEALTH SUPPLIES
6.1 STOCK STATUS (Out of stock means that there was NONE left in your health unit STORE)
Note: The primary data sources for this sub-section are the Stock books and Stock Cards

Quantity
Days out of Stock on Quantity
SN. NAME OF DRUG ITEM UNIT Consumed
stock hand expired
(units)
SS01 Artemether/Lumefantrine 20/120 mg Tablet
SS02 Depot medroxy progesterone acetate (DMPA) Injectable
SS03 Amoxicillin 250 mg capsule Capsule
SS04 Sulfadoxine/ Pyrimethamine tablet Tablet
SS05 ORS Sachets with zinc tablet Packet
SS06 Measles Vaccine Vial
SS07 Determine HIV 1 & 2 screening test Tests
SS08 Stat -pack HIV Confirmatory rapid tests, tests Tests
SS09 SD Bioline test Tie-Breaker Tests
SS10 CD4 reagent Tests
SS11 Malaria Rapid Diagnostic tests Tests
SS12 GeneXpert Cartridges Cartridges
SS13 Therapeutic milk F75 (75Kcal/100ml) Packet
SS14 Oral Liquid Morphine 5ml/ml Bottle of 500 ml
SS15 Ready to use Therapeutic feeds (RUTF) Sacket
SS16 TDF/3TC/EFV 300mg/300mg/(600mg or 400mg )tablet Pack of 30
SS17 AZT/3TC/NVP 300mg/150mg/200mg Pack of 60
SS18 Atazanavir /ritonavir (ATV/r) 300/100mg tablet Pack of 30
SS19 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30
SS20 TDF/3TC/DTG 300mg/300mg/50mg(TLD) Pack of 30
SS21 TLE 300mg/300mg/400mg Pack of 90
SS22 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg (Paediatric) Pack of 30
SS23 Lopinavir 40mg/ritonavir 10mg pellets in capsules Pack of 120
SS24 Cotrimoxazole 960mg tablet Pack of 1000
SS25 (RHZE) blister strip 150/75/400/275 mg 28 tablets
SS26 Blood 450 ml Unit
SS27 RHZ Blister 75mg/50mg/150mg 28 tablets
SS28 Misoprostol 200mcg Tablet** Tablet
SS29 Amoxicillin dispersible 250mg tablet. Tablet
SS30 Ceftriaxone 1g Injection Vial
SS31 Oxytocin Injection Ampoule
Chlorhexidine Digluconate Gel 7.1% (equivalent to 4%
SS32 Tube
chlorhexidine)
SS33 Mama Kit** Kit
SS34 Bendroflumethiazide (Aprinox) 5mg Tablet
SS35 Artesunate 60mg Injection
SS36 Nifedipine tablets 20mg tablet Tablet
SS37 Captopril 25mg tablet Tablet
SS38 Metformin 500mg Tablet
SS39 Glibenclamide 5mg tablet Tablet
SS40 Insulin short-acting Vial
SS41 Cardiac Aspirin 75/80 mg Tablet

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 25
6.2 ADD THE GENERIC NAME OF DRUGS, VACCINES, CONTRACEPTIVES OR SUPPLIES THAT HAVE EXPIRED DURING THE MONTH:
NO. ITEM NAME OF DRUG ITEM Quantity NO. ITEM NAME OF DRUG ITEM Quantity
CODE CODE
1 6
2 7
3 8
4 9
5 10
7.0 OUTREACH ACTIVITIES Number Planned Number Conducted
OH01. EPI Outreaches
OH02. HCT Outreaches
OH03. Environmental Health Visits
OH04. Health Education/Promotion Outreaches
OH5. Maternal Deaths Audited/Reviewed ( community Verbal autopsy)
OH06.Perinatal Deaths Audited
OH07. Integrated SRH services outreaches (FP, ANC, PNC, ASRH, ADH, CaCx screening,
Fistula screening & reintegration, GBV etc)
OH08. Number of surgical and Treatment camps (e.g, Fistula repair, Gynaecological camps etc)
OH09. School health outreaches
OH10. Total Number of Births registered during outreaches
OH11. Other Outreaches
8.0 MEETINGS Number Planned Number Conducted
MT01. General Staff Meetings
MT02. Quality Improvement (QI) Meetings
MT03. Maternal& Perinatal Death Review committee Meetings
MT04. Health Unit Management Committee/Hospital Board Meetings
MT05. Community Accountability and client feedback review meetings ( Eg. Balazas, Community
meetings, community feedback meetings etc)
MT06. Other Meetings
Health Education at Health Facility level Number Planned Number Conducted
MT07. Health Education sessions at Health facility
10-19 Years 20-24 years
Adolescent /youth friendly services
Male Female Male Female

MT08.Number of adolescents who accessed adolescent friendly corner New

for any service Revisit
9.0 SUPPORT SUPERVISION VISITS Number Planned Number Conducted
SV01. From Ministry of Health
SV02. From Regional Teams
SV03. From District Local Government
SV04. From the Health Sub-District (HSD)
SV05. Other Support Supervisions done

LABORATORY
10.1.1. Total 10.1.2. Number of Specimen Collected at Facility and Received from other
number of laboratory client facilities (For tests done within)
visits
Blood Stool/ Urine Sputum CSF Pus Genital Skin Others
Rectal Swab Swab Snip
swab
LV01. SC01.
Outpatient Collected (IN)
(OPD)
LV02. SC02.
Inpatient Received
(IPD) (OUT)

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 26
10.2 LABORATORY ROUTINE TESTS
10.2.1 Number of Routine Tests Done in Facility Laboratory
Number Number Number Number
Lab Tests Lab Tests
Done Positive Done Positive
HEMATOLOGY (BLOOD) SEROLOGY
HE01. Hb (Non automated) SR01.VDRL/ RPR
HE02. CBC SR02.TPHA
HE03. Film Comment SR03.Shigella Dysentery
HE04. ESR SR04. Hepatitis B SAgS
HE05. Bleeding time SR05. Brucella
HE06. Prothrombin time SR06. Pregnancy Test (HCG)
HE07. Clotting time SR07. CRAG
HE08. Sickle Cell SR08. Rheumatoid factor
HE09. Others SR09. Hep B Core Ag
BLOOD TRANSFUSION SR10. Hep C
BT01. AHG (Comb’s Test) SR11. Hep A
BT02. ABO Grouping MICROBIOLOGY (CSF, URINE, STOOL, BLOOD, SPUTUM, SWABS)
BT03. Rhesus Grouping MB01. Auramine (FM) for AFBs
BT04. Cross Matching MB02. ZN for AFBs
IMMUNOLOGY MB03. Leishman Stain
IG01. CD4 test MB04. Gram
IG02. Viral Load Test MB05. India Ink
IG03. Hep B Viral Load MB06. Urine Microscopy
IG04. TB LAM MB07. Wet Preps
MOLECULAR MB08. Others

ML01. TB Genexpert MTB+ CLINICAL CHEMISTRY

(For Genexpert sites only) RR Renal Profile
ML02. Latent TB Infection test RP01. Urea
ML03. TB Lamp Test RP02. Calcium
PARASITOLOGY(Blood) RP03. Potassium
PS01. Malaria Microscopy RP04. Sodium
PS02. Malaria RDTs RP05. Creatinine
PS03. Trypanosoma Liver Profile
PS04. Microfilaria LP01. ALT
PS05. Leishmania LP02. AST
PS06. Trichinella LP03. Albumin
PS07. Borrellia LP04. Total Protein
STOOL MICROSCOPY Lipid/Thyroid Profile
MS01. Entamoeba LC01. Triglycerides
MS02. Giardia Lumblia LC02. Cholesterol
MS03. Cryptosporidium LC03. Free T3
MS04. Isospora LC04. Free T4
MS05. Cyclospora LC05. TSH
MS06. Strongyloides Other Clinical Chemistry Tests
MS07. Shistosoma CX01. Alkaline Phosphate
MS08. Taenia CX02. Amylase
MS09. Askaris CX03. Glucose
MS10. Hookworm CX04. Total Bilirubin
MS11. Trichuris CX05. Lipase
MS12. Other parasites CX06. AFP
MS13 Total Tests Done for Stool Microscopy CX07. Others

Print Version September 2019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 27
Number Number
Lab Tests (Continued)
Done Positive
CULTURE & SENSITIVITY
CS01. Blood
CS02. Urine
CS03. Stool
CS04. Genital Swabs
CS05. Sputum
10.3 SUMMARY OF HIV TESTS BY PURPOSE
Test for Incon- DNA
Clinical Recency Repeat
Category HCT eMTCT SMC Verifi- IQC EQA Total clusive Confirmed
Diagnosis Testing Testers
cation Results Tests
HP01. Determine
HP02. Statpak
HP03. SD Bioline
HP04. HIV Syphilis DUO
HP05. Oraquick (Self Testing)
10.4 REFERRAL TESTING
10.4.1 Volume of Sample Referred
No. of No. of
No. of Average No. of Average
Pending Pending
Type of Test Specimen Turn Around Type of Test Specimen Turn Around
Results/ Results/
Referred Time (Days) Referred Time (Days)
Feedback Feedback
Virology Microbiology(Continued)
VS01. EID VS15. Neonatal tetanus
VS02. Viral Load for HIV VS16. Plague
VS03. CD4 VS17. Isolates
VS04. Sickle Cell Disease VS19. Viral Haemorrhagic
Confirmation Fevers(VHF)
VS05. Histology
VS20. Animal Bites
VS06. Polio/or Acute Flaccid (suspected rabies)
Paralysis
VS07. Severe Acute Respi- VS21. Suspected outbreak
ratory Syndrome/Infection samples (EBOLA, Marburg,
(SARS/SARI) others)
VS08. TB GeneXpert VS22. Hepatitis B core Ag
VS09. DST for Multi Drug VS23. Hepatitis B Viral Load
Resistance TB (MDR TB)
Microbiology VS24. Hepatitis C Viral load
VS10. Typhoid Fever Parasitology
VS11. Cholera VS25. Hemo parasites
VS12. Dysentery VS26. Intestinal parasites
VS13. Rota Virus VS27. Tissue parasites
VS14. Meningitis Totals
10.5 Number of Routine Tests that could not be conducted at facility and were referred to hub or other facility

Routine Test Type Reasons for Referrals and Reasons for not conducting tests that are on test menu
(specify type test)
Equipment Reagent Supplies Power No testing Lack of Confirmatory For QA Others
break down stock out stock out outage expertise required testing re-testing
equipment
RT01. CD4
RT02. TB
RT03. CBC
RT04. Chemistry
RT05. Microbiology
RT06. HIV screening
RT07. VDRL
RT08. Haematology
RT09. Parasitology

Print Version September 2019

HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 28

10.6 AMR SURVEILANCE

10.6.1 National Priority AMR Organisms
WHO Priority AMR Organisms Other AMR Organisms

Staphylococcus

Campylobacter.
Escherichia coli

Salmonella spp

Vibrio cholera.
Streptococcus

Acinetobacter

Enterococcus

meningitides.
Haemophilus
gonorrhoeae
pneumoniae

pneumoniae
Shigella spp

baumannii
Organisms

Klebsiella

influenza.
Neisseria

Neisseria
aureus

Others
spp.
NP01. No. of Isolates
ANTIBIOTICS R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S R I S
NP02. Ampicilin
NP03. Azithromycin
NP04.Amikacin
NP05.Ceftriaxone
NP06.Ceftazidime
NP07.Cefotaxime
NP08.Cefoxitin
NP09.Cefixime
NP10.Cotrimoxazole
NP11.Ciprofloxacin
NP12.Colistin
NP13.Gentamicin
NP14.Imipenem
NP15.Levofloxacin
NP16.Meropenem
NP17.Oxacillin
NP18.Penicillin G
NP19.Vancomycin
NP20. Augmentin
NP21.Chloramphenicol
NP22.Clindamycin
NP23.Erythromycin
NP24.Nalidixic acid
NP25.Nitrofurantoin
NP26.Piperacillin
NP27.Piperacillin/
Tazobactam
NP28.Tetracycline

Print Version September 20019

 HMIS 105: HEALTH UNIT OUTPATIENT MONTHLY REPORT Page 29
10.7. LABORATORY SPECIMEN REJECTION
Sample Type
Reasons for Specimen Rejection Stool/
Pus Genital Skin
Blood Rectal Urine Sputum Others
Swab Swab snip
Swab
RS01. Inadequate specimen volume
RS02. Hemolyzed specimen
RS03. Specimen without lab request form
RS04. No test specified on lab request form accompanying
specimen
RS05. Specimen without label or identifier
RS06. Wrong specimen label
RS07. Unclear specimen label
RS08. Wrong specimen container
RS09. Damaged specimen container
RS10. Too old specimen
RS11. Date of specimen collection not specified
RS12. Time of specimen collection not specified
RS13. Specimen type unacceptable for required test
RS14. Other reasons
Totals

12. COMMENTS BY HEALTH FACILITY IN CHARGE:

.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................

Date of Report:...................................................
Health Unit In-charge: Name:...............................................................................Title:................................Signature:...............................
Phone No.:........................................................ Email:................................................................................................................................

- - - - - - - - - - - - - - -- - - - - - - - - - - (District/HSD use only)- - - - - - - - - - - - - - - - - - - - - -- - - - - -

Date received
Received by 7th of next month Yes No
Checked by (signature)
Date Entered
Name of Data Entrant

COMMENTS BY HSD:................................................................................................................................................................................

.....................................................................................................................................................................................................................

.....................................................................................................................................................................................................................

.....................................................................................................................................................................................................................

__________________________________________________________________________________________________________

Print Version September 2019