SCHOOL OF NURSING

Andres Bonifacio College

College Park, Dipolog City

Assignment in
NCM 211

FHSIS COMPONENTS

SUBMITTED BY:
Kate S. Casanes

SUBMITTED TO:
Mrs. Precy Nelia C. Gilaga

December 10, 2020

FHSIS

The Field Health Service Information System (FHSIS) is a major component of the
network information sources developed by the Department of Health (DOH) to enable it to
better manage its nationwide health service delivery activities. This has been designed to
provide the basic service data needed to monitor activities in each program. Additional
information relevant to these programs will be available from other sources such as Hospital
Services Information System, Financial Information System, Physical Resources Information
System and Human Resources Information System.

FHSIS COMPONENTS

1. Individual Treatment Record (ITR)

The fundamental building block or foundation of the Field Health Service Information
System is the INDIVIDUAL TREATMENT RECORD. This is a document, form or piece of paper
upon which is recorded the date, name, address of patient, presenting symptoms or
complaint of the patient on consultation and the diagnosis (if available), treatment and date
of treatment. This record will be maintained as part of the system of records at each health
facility on all patients seen. This record may be as simple as the following example prepared
on plain bond paper:

Sample of ITR:

DELA CRUZ, ROSE M.

2106 Rizal Avenue, Siniloan, Laguna

Age: 25 years Birthday: February 7, 1980
Religion: Catholic Weight: 115 lbs
Occupation: Housekeeper

4/15/2007
Complaint: Headache & vomiting
Vital signs: BP = 120/80 mmHG
Diagnosis:
Treatment/Recommendations:

NOTE: Do not rely on records maintained by the client/patient. In areas where the
home based maternal record is in use, there must still be a treatment record
available in the facility.

2. Target Client List (TCL)

The Target Client Lists constitute the second “building block” of the FHSIS and are
intended to serve several purposes. First is to plan and carry out patient care and service
delivery. Such lists will be of considerable value to midwives/nurses in monitoring service
delivery to clients in general and in particular to groups of patients identified as “targets” or
“eligibles” for one or another program of the Department. The primary advantage of
maintaining the Target Client Lists is that the midwife/nurse does not have to go back to
individual patient/family records as frequently in order to monitor patient treatment or
services to beneficiaries. The second purpose of Target Client Lists is to facilitate the
monitoring and supervision of service delivery activities. The third purpose is to report
services delivered. Again, the objective is to avoid having to go back to individual
patient/family records in order to complete the FHSIS Reporting The fourth purpose of the
Target Client Lists is to provide a clinic-level data base which can be accessed for further
studies The Target Client Lists to be maintained in the FHSIS version 2008 are as follows:
Ø Target Client List for Prenatal Care
Ø Target Client List for Post-Partum Care
Ø Target Client List of Under 1 Year Old Children
Ø Target Client List for Family Planning
Ø Target Client List for Sick Children
Ø NTP TB Register (same as program)
Ø National Leprosy Control Program Form 2-Central Registration Form

Guide for Filling Up

Target Client List for Prenatal Care
The target client list for prenatal care will include all pregnant women eligible for
pre-natal care/service. The individual patient record or pre-natal record must still be
maintained together with this list to record information of importance to the patient which
otherwise is not included in the client list (e.g. the FHB, Wt., BP) for every pre-natal visit.

The target client list must be properly filled-up and updated as soon as possible
following patient’s visit by the midwife in the BHS and the nurse/midwife in the RHU. The
trained BHW can also be given the responsibility of recording provided they are under the
direct supervision of the nurse or midwife.

Column 1 – DATE OF REGISTRATION – Write in this column the month, day and year a
pregnant woman was first seen at the clinic for pre-natal visit.

Column 2 – FAMILY SERIAL NUMBER – Enter in this column the number that corresponds to
the number of the family folder or envelope or individual treatment record. This column will
help you to easily facilitate retrieval of your record.

Column 3 - NAME – Write the given name, middle initial and family name of the woman.

Column 4 – ADDRESSES – Write the complete address: number of the house, name of the
street, barangay, municipality and province. This column will help you to monitor or follow-
up the client.

Column 5 – AGE – Write the age of the woman at her last birthday.

Column 6 – LAST NORMAL MENSTRUAL PERIOD /GRAVIDA-PARITY – LMP/GP - Write in this

column 2 entries. First is the date of the last menstrual period (month, first day of LMP and
the year) followed by gravida-parity (G-P) of the client. LMP is important because this is the
basis for computing the EDC of the mother while GP is important to know if pregnancy is of
risk.

Example:

(5) LMP/G-P (7)

(6)
2-14-07/
4-3

This means that the last menstrual period of the woman was 2-14-07 and she had 4
pregnancies (gravida) including the current pregnancy and 3 deliveries (parity).
Column 7 – EDC or EXPECTED DATE OF CONFINEMENT – Write in this column the expected
date of delivery. This column is important for follow-up visits to prevent post maturity.

Formula for Computing EDC:

LMP: January-March = + 9 mos. + 7 days + 0
April-December = - 3 mos. + 7 days + 1 year
Example: LMP = 4 14 2007
Formula = - 3 + 7 + 1
EDC = 1 21 2008

Column 8 – PRENATAL VISIT (DATES) – This has 3 sub-columns representing the trimester of
pregnancy. All dates of pre-natal visits either clinic or home of a particular pregnant woman
must be entered in this column corresponding to the trimester of pregnancy when the visit
was undertaken. If a pregnant woman comes in the clinic in the first 3 months of her
pregnancy (i.e. first trimester) enter the date of that check-up under column 8, 1st
trimester. Dates of all succeeding visits should be indicated in the appropriate trimester
column. It is possible that more than one date appears in each column. Also, visits from
other DOH facilities, private hospital/clinic should also be recorded in this column as long as
there’s a way to validate that the visit is a PNV. This column is important for early detection
of risk pregnancies thus protecting both the mother and the baby.

Trimesters of Pregnancy:
The First Trimester = the first 3 months (up to 12 weeks)
The Second Trimester = the middle 3 months (13-27 weeks)
The Third Trimester = the last 3 months (28 weeks and more)

Column 9 – TETANUS STATUS – Write in this column the tetanus toxoid immunization
already
received by the pregnant woman (either from the past pregnancy or present pregnancy)
when she made her first visit to the facility. The record of past pregnancies can be used to
obtain this information. Use the following codes:

CODE
TT1 The woman has received only one dose of tetanus toxoid during this
pregnancy from other DOH facility (e.g transferred residence)
TT1 & TT2 The woman has received 2 doses of tetanus toxoid this pregnancy from
other DOH facility (e.g. transferred residence) and any woman who has
received TT1 and TT2 during the past pregnancy.
TT3 The woman has received TT1 and TT2 together with TT3
TT4 The woman has received TT1, TT2, TT3 and TT4
TT5 The woman has received TT1, TT2, TT3, TT4 and TT5
TTL Presently pregnant woman who already received
the 5 doses tetanus toxoid (Fully Immunized Mother)
NONE Women without previous history/record of
tetanus immunization or women having her pre-natal
visit for her first pregnancy
UNKNOW If no information can be obtained from the records or
N history of the woman.
Column 10 - TETANUS TOXOID VACCINATION GIVEN – Write in this column the date each
tetanus toxoid is given during the course of the present/current pregnancy.

Tetanus Toxoid (TT) Immunization Schedule

TT DOSE INTERVAL
TT1 As early as possible during first pregnancy or even in a non-pregnant child
bearing age woman
TT2 4 weeks after first dose within the same pregnancy
TT3 6 months after TT2
TT4 1 year after TT3
TT5 1 year after TT4

Column 11 – MICRONUTRIENT SUPPLEMENTATION – This has 2 sub columns iron and

Vitamin
A supplementation. For Vitamin A column, write the date and for iron column write
the date and number of iron with folic acid supplementation was given to pregnant
woman during visit.

Column 12 – RISK FACTOR/DATE DETECTED –Indicate in this column the risk factor (use
codes) and the date this was detected. It is possible that several codes appear in this
column. Risk factors are conditions that a woman has in her medical history or history
of previous pregnancies or deliveries, which put her at risk for complications in this
pregnancy and/or delivery. Use the following codes/factors for risk pregnancy.

CODES RISK FACTORS REASON

A An age less than 18 or
greater than 35
B Being less than 145 cm (4’9”) At risk of cephalo-pelvic disproportion
tall
C Having a fourth (or more) baby The mother is most likely to have
(or so called multiparous) postpartum hemorrhage or malpresentation
D Having with one or more of ff:
- a previous caesarian section - She may need another
caesarian section
- 3 consecutive miscarriages or - She may have a condition that
a stillborn baby causes miscarriages and
needs treatment or she may
have an abnormal labor or a
disease such as diabetes
which needs treatment
- postpartum hemorrhage - She may have another
postpartum hemorrhage with
this delivery
E Having one or more of the
following medical conditions:
- Tuberculosis
- Heart Disease
- Diabetes
- Bronchial Asthma
- Goiter
If the mother had any of these factors or history of any of them, she should be closely
monitored by the midwife or referred to a physician, she will probably need to deliver the
baby in the hospital.

Column 13 – PREGNANCY – Write the date (month, day and year) when the current
pregnancy was terminated in the sub-column DATE TERMINATED and, in the OUTCOME,
sub-column, write the outcome of the pregnancy whether it is a live birth, stillbirth or
abortion and the sex. It is possible that two codes appear in this sub-column. Use the
following codes:

CODE DEFINITION
LB Livebirth - the complete expulsion or extraction from the mother’s womb of a
product of conception, irrespective after such separation, breathes or shows any
other evidence of life such as beating of the heart, pulsation of the umbilical cord
or
definite movement of muscles.
SB Stillbirth – death of the fetus prior to the complete expulsion from the mother;
the death is indicated by the fact that after separation, the fetus does not breath
or show any evidence of life such as beating of the heart, pulsation of the
umbilical cord or definite movement of voluntary muscles. (20 weeks and
above)
AB Abortion – termination of pregnancy before the fetus becomes viable. (before
the 20th week or 5 months of pregnancy)

Column 14 – LIVEBIRTHS – In case of live birth, the weight of the infant in grams must
appear in the BIRTHWEIGHT sub-column. If there is more than 1 birth, all birth weights in
grams must appear. In the PLACE OF DELIVERY sub-column, write “home” if delivery
occurred at home, “hospital” if delivery occurred in the hospital and so on. It is possible that
two entries appear in this sub-column in case of multiple births at different places. In the
ATTENDED sub-column, write the corresponding code of the person’s designation with the
highest professional rank.

CODE DESIGNATION
A Doctor
B Nurse
C Midwife
D Hilot/TBA
E Others

Column 15 – REMARKS – Make a note under this column why a pregnant woman failed to
return for the next prenatal care. Indicate dates and reasons such as transferred to
another province, presently ill, hospitalized, etc. Also include other data of
importance to the patient.

Target Client List for Post-Partum Care

The Target Client List for Post-Partum Care will include all the women within the
catchment area who had a delivery. This list should be considered as an extension of the
TARGET CLIENT LIST FOR PRE-NATAL CARE. The names of women are entered upon
termination of pregnancy or women, whose terminations of pregnancy were not attended
by the midwife or nurse, their names are also entered in the list upon knowledge of a birth
in the catchment area, visit to facility or a home visit.
 The list must be properly updated and exact dates indicated in each column by
responsible personnel i.e. the midwife in the BHS, the nurse or the midwife in the RHU or
the trained BHW under the direct supervision of the nurse or midwife.

Column 1 – DATE AND TIME OF DELIVERY – Write in this column the month, day, year and
time of termination of pregnancy of the mother.

Column 2 – FAMILY SERIAL NUMBER – Enter in this column the number that corresponds to
the number of the family folder or envelope or individual treatment record. This
column will help you to easily facilitate retrieval of your record.

Column 3 - NAME – Write the given name, middle initial and family name of the woman.

Column 4 – ADDRESSES – Write the complete address: number of the house, name of the
street, barangay, municipality and province. This column will help you to monitor or
follow-up the client.

Column 5 – DATE OF POSTPARTUM VISITS – This column is divided into two sub-columns.
Write the date of postpartum visits at home or at the clinic within 24 hours upon
delivery and within one week after delivery.

Column 6 – DATE AND TIME INITIATED BREASTFEEDING – write the date and the time
postpartum mother initiated breastfeeding.

Column 7 – DATE SUPPLEMENTATION WAS GIVEN – This column is divided into iron and
vitamin supplementation. For iron supplementation column, write the date/s and
number of tablet given to post-partum women. For Vitamin A, write only the date
supplementation was given.

Column 8 – REMARKS – Under remarks column enter information which you feel important
for post-partum care mothers.

Target Client List for Family Planning

The Target Client List for Family Planning will include all eligible women aged 15-49
and men who are receiving a family planning service provided by the reporting clinic. The
Family Planning Service provided by the reporting clinic will include Condom, Depo-medroxy
Progestone Acetate (DMPA), Intra-Uterine Device (IUD), NFP-Lactational Amenorrhea
Method (NFP-LAM), NFP-Basal Body Temperature (NFP-BBT), NFP-Cervical Mucus Method
(NFP-CM), NFP-Sympothermal Method (NFP-STM), NFP-Standard Days Method (NFP-SDM)
Pills, Female Sterilization/Bilateral Tubal Ligation (FSTR/BTL) and Male
Sterilization/Vasectomy. The Target Client List should be by Family Planning Method and be
updated immediately after a client visits the facility.

Column 1 – DATE OF REGISTRATION – Indicate in this column the date (month, day and
year) an eligible person made the first clinic visit or the date when client re-start to avail
Family Planning Service.

Column 2 - FAMILY SERIAL NUMBER – Indicate in this column the number that corresponds
to
the number of the family folder or envelope or individual treatment record. This
column will help you to easily facilitate retrieval of your record.

Column 3 – NAME – Write the given name, middle initial and family name of the client.
Column 4 – ADDRESS – Write the complete address: number of the house, name of the
street, barangay, municipality and province. This column will help you to monitor or
follow-up the client.

Column 5 – AGE – Indicate in this column the age of the client as of last birthday.

Column 6 – TYPE OF CLIENT – Indicate in this column any of the following categories:
CODES TYPE OF CLIENT
CU Current Users – current users carried over from last year client list.
NA New Acceptors – a client who has NEVER accepted any FP method at any clinic
before
CM Changing Method – a user who is shifting to another Method
CC Changing Clinic – a continuing users using the same method, however the client
is new to the clinic
RS Restart – a client who is previously a drop-out or stop using a FP method and
who has accepted a FP method again. Classify as a re-start but considered as
current users.

NOTE: For clients who are changing methods, they should be recorded as a DROP-OUT from
their previous method and indicate the reason as ‘CHANGING METHOD”. The client is still
categorized as current users.

Column 7 – PREVIOUS METHOD – refers to last method used prior to accepting the new
method. Using the following codes Add code for NONE to cover “New to Program

CODES METHODS
CON Condom
INJ Depo-medroxy Progestone Acetate (DMPA)
IUD Intra-Uterine Device
NFP-LAM Lactational Amenorrhea Method
NFP-BBT Natural Family Planning-Basal Body Temperature
NFP-CM Natural Family Planning-Cervical Mucus Method
NFP-STM Natural Family Planning-Sympothermal Method
NFP-SDM Natural Family Planning-Standard Days Method
FSTR/BTL Female Sterilization/Bilateral Tubal Ligation
MSTR/VASECTOMY Male Sterilization/Vasectomy
PILLS Pills

Column 8 – FOLLOW-UP VISITS – Write in this column 2 entries, in the upper space is the
scheduled date of visit and at the lower space is the actual date of visit. A client who is
scheduled for a particular month and failed to make the clinic visit will have only one date
entered in that particular month.

Column 9 – DROP-OUT – If a client failed to return for the next service date, he or she is
considered to be a drop-out. Enter the date the client became a drop-out under the
column “Date” and indicate the reason under column “Reason”. Possible reasons
include: (use letter codes).
CODE REASON
A Pregnant
B Desire to become pregnant
C Medical complications
D Fear of side effects
 E Changed clinic
F Husband disapproves
G Menopause
H Lost or moved out of the area or residence
I Failed to get supply
J IUD expelled
K Lack of supply
L Unknown

The following are the definitions for each method drop-out:

a. Pill - A client is considered drop-out from the method if she failed to come and get her re-
supply from the last 21 white pill up to the last brown pill. The service provider should
undertake a follow-up visit of the client within this period before dropping her from the
method.
b. DMPA – A client is considered drop-out if she failed to visit the clinic on the scheduled
date of visit up to the last day of 2 weeks after the scheduled date of visit. The service
provider should undertake a follow up visits during the above period prior to dropping her
out from the
method.
c. IUD – client is considered drop-out if:
c.1 client decided to have it removed
c.2 had expelled IUD that was not re-inserted and
c.3 client did not return on the scheduled date of follow-up visits for the
first year after insertion follow-up visits should be after one month, six
months, and twelve month and yearly thereafter. Follow up of the client
should be done before dropping her out from the method.
d. Condom – client is considered drop-out if she/he fails to return
for resupply on scheduled visit
e. LAM – client is considered drop-out if any one of the three (3) conditions is
not met as follows:
e.1 Mother has no menstruation or amenorrheic within six months. Spotting or bleeding
during the last fifty-six (56)
days postpartum is not considered return of menses.
e.2 Fully/exclusive breastfeeding means no other liquid or
solid except breastmilk be given to the infant, intervals
should not exceed four hours during the day and six
hours at night.
e.3 Baby is less than six (6) months old
f. NFP- client is considered drop-out if the client fails to return to the clinic from
the last 2 weeks of the 3rd cycle to be validated by the service provider
and to get NFP autonomous user chart for succeeding cycles.

g. Voluntary Surgical Contraception

a. Female Sterilization – client is considered drop-out if woman reaches
her menopausal age (45 years and above) and other conditions that the
client undergo such as hysterectomy or bilateral salpingo-oophorectomy.
NOTE: Follow up of clients should be undertaken prior to the dropping out of the
client from the method.
Column 10 – REMARKS – Indicate in this column the date and reason for every referral
MADE to other clinic and referral RECEIVED from other clinic which can be due to
medical complications or unavailable family planning services and other pertinent
findings significant to client care.
Target Client List for Under One Year Old Children
The Target Client List for Under One Year Old Children should include all children under one
year old eligible for immunization against the seven (7) vaccine preventable diseases (VPD),
iron supplementation, newborn screening and breastfeeding. An entry should be made on
this list when a delivery is made of pregnant women on the TCL-PN. Also, include list of
eligible newborns and infants from the local birth registration office and from births that
occurred within the community including transferees to have a complete list of expected
number of children. The updated recording of this list is the responsibility of the midwife in
the BHS and the nurse/midwife in the RHU. A trained BHW or volunteer can also be given
the
responsibility of recording provided they are under the supervision of the nurse/midwife.

Column 1 – DATE OF REGISTRATION – Write in this column the month, day and year an
infant
was seen at the clinic or at home for health services.

Column 2 – DATE OF BIRTH – Write in this column the month, day and year of birth. This
column is important for immunization schedule.

Column 3 - FAMILY SERIAL NUMBER – Indicate in this column the number that corresponds
to
the number of the family folder or envelope or individual treatment record. This
column will help you to easily facilitate retrieval of your record.

Target Client List for Under One Year Old Children

The Target Client List for Under One Year Old Children should include all children under one
year old eligible for immunization against the seven (7) vaccine preventable diseases (VPD),
iron supplementation, newborn screening and breastfeeding. An entry should be made on
this list when a delivery is made of pregnant women on the TCL-PN. Also, include list of
eligible newborns and infants from the local birth registration office and from births that
occurred within the community including transferees to have a complete list of expected
number of children. The updated recording of this list is the responsibility of the midwife in
the BHS and the nurse/midwife in the RHU. A trained BHW or volunteer can also be given
the responsibility of recording provided they are under the supervision of the
nurse/midwife.

Column 1 – DATE OF REGISTRATION – Write in this column the month, day and year an
infant was seen at the clinic or at home for health services.

Column 2 – DATE OF BIRTH – Write in this column the month, day and year of birth. This
column is important for immunization schedule.

Column 3 - FAMILY SERIAL NUMBER – Indicate in this column the number that corresponds
to the number of the family folder or envelope or individual treatment record. This
column will help you to easily facilitate retrieval of your record.

Column 4 – NAME OF CHILD – Write the complete name of the child.

Column 5 – SEX – Write the sex of infant. M for male and F for female.

Column 6 – COMPLETE NAME OF MOTHER – Write in this column the name of the mother
Column 7 – COMPLETE ADDRESS – Record the client’s permanent place of residence. This
column will help you to monitor or follow-up the client.
Column 8 – DATE OF NEWBORN SCREENING – This is divided into two sub-columns. The first
sub-column refers to those given referral only and on the second sub-column refers to
newborn screening done in your health center. Only write the date.

Column 9 - CHILD PROTECTED AT BIRTH (CPAB) – Write the Tetanus Toxoid Status of the
mother in the sub-column TT STATUS and Date the mother was assess of her TT status.

Column 10 – MICRONUTRIENT SUPPLEMENTATION– This column consists of 2 sub-columns.

For Vitamin A Supplementation column, write the age in months and the date Vitamin
A was given and on the Iron column write the birthweight of the infant and the date
iron was started given and date completed.

Column 11 – DATE IMMUNIZATION RECEIVED – Indicate in these columns the exact date the
child received each antigen or vaccine.

Routine Immunization Schedule for Infants

Vaccine Age No. of Reason

Doses
BCG Birth or 1 BCG is given at the earliest
Anytime after birth possible age protects against
the possibility of infection
from other family member
DPT1 6 weeks 3 An early start with DPT
DPT2 10 weeks reduces the chance of
DPT3 14 weeks severe pertussis, diphtheria
and tetanus
OPV1 6 weeks 3 The extent of protection
OPV2 10 weeks against polio is increased
OPV3 14 weeks the earlier the OPV is given
HepaB1 Birth (w/in 24 hrs) 3 An early start of Hepatitis B
HepaB2 6 weeks reduces the chance of being
HepaB3 14 weeks infected and becoming a
carrier
Measles 9 months 1 At least 85% of measles can
be prevented by
immunization at this age
Column 12 – DATE FULLY IMMUNIZED – Write the exact date the child was given the last dose
of the scheduled immunization which makes the child a fully immunized child.

Note: A Fully Immunized Child (FIC) is a child that has received all of the following:

a. One dose of BCG at birth or anytime before reaching 12 months

rd
b. 3 doses each of DPT , OPV and Hepa B as long as the 3 dose is
given before the child reaches 12 months of age.
c. One dose of anti-measles vaccine before reaching 12 months

Column 13 – CHILD WAS EXCLUSIVELY BREASTFED – This column is divided into 6 sub-
columns. For sub-columns “1st to 5th month”, put a check if the child was exclusively
breastfed while for sub-column “6th month”, write the date if the child was exclusively
breastfed.

Column 14 – REMARKS – Write the reasons why a child failed to return for the next
immunization schedule or why a child reaching 1 year of age was not fully immunized,
to include illnesses, hospitalization, and other data of importance to the child.

Target Client List for Sick Children

The Target Client List for Sick Children should include all children under 6 years of age (1) who
are sick with Measles, Severe Pneumonia, persistent Diarrhea, Malnutrition, Xerophthalmia,
Night Blindness, Bitot’s spots, Corneal Xerosis, Corneal Ulcerations and Keratomalacia and are
eligible for Vitamin A supplementation (2) Anemic children who are eligible for Iron; (3)
Children with Diarrhea and (4) Children with Pneumonia.

The updated recording of this list is the responsibility of the midwife in the BHS and the
nurse/midwife in the RHU. A trained BHW or volunteer can also be given the responsibility of
recording provided they are under the supervision of the nurse/midwife.

Column 1 – DATE OF REGISTRATION – Indicate in this column the date (month, day and year)
the child was identified to be sick.

Column 2 - FAMILY SERIAL NUMBER – Indicate in this column the number that corresponds to
the number of the family folder or envelope or individual treatment record. This
column will help you to easily facilitate retrieval of your record.

Column 3 – NAME OF CHILD – Write the complete name of the child.

Column 4 – DATE OF BIRTH – Write in this column the month, day and year of birth.

Column 5 – SEX – Write the sex of infant. M for male and F for female.
Column 6 – COMPLETE ADDRESS – Record the client’s permanent place of residence. This
column will help you to monitor or follow-up the client.

Column 7- VITAMIN A – On the first sub-column, put a check in the column that corresponds
to the following age-group: 6-11, 12-59 and 60-71 months. For the second sub-column,
write the corresponding codes for the diagnosis/findings and on the last column write
the date Vitamin A was given. Use the following codes for diagnosis/findings:

Code Diagnosis/Findings Definition

A Measles
B Severe Pneumonia
C Persistent Diarrhea
D Malnutrition
E Xerophthalmia
• History of fever (38C or more) or hot to
touch; and
• generalized non-vesicular rash of 3
or more days duration and
•at least one of the following: cough,
coryza or conjunctivitis
Presence of any general danger
sign or chest indrawing or stridor
in calm child
An episode of soft to watery
Stools lasting more than 14 days
Children whose weight are
Classified as below normal or
Very low below normal
Used to include all signs and symptoms
affecting the eye that can be attributed
to Vitamin A deficiency. It Includes
ocular manifestation of VAD
like nightblindness, conjunctival xerosis,
bitot’s spots, corneal xerosis, corneal
ulcer/keratomalacia and corneal scar.

F Night Blindness Described as having difficulty in seeing

in the dark with the child refusing to
play after dusk, stumbles on furniture,
gropes for food, as questions at dusk
like: It is already dark? Where is the
door?

G Bitot’s spots - These are foamy, soapy, whitish patches

seen in the white part of eye (scleral
conjunctiva). Frequently associated with
Nighblindness. It can be removed but
may re-accumulate later.
 H Corneal Xerosis
I Corneal Ulcerations
Cornea is cloudy and dry with an orange-
peel appearance. Some people call this
fish scale over the years. Child’s vision
is diminished even at daytime
- Cornea becomes soft, bulges with large
perforation or holes in the surface.
Children with prolonged diarrhea and
measles frequently develop this stage.

J Keratomalacia - Cornea becomes soft, bulges with large

perforation or holes in the surface.
Children with prolonged diarrhea and
measles frequently develop this stage.

Schedule of High Dose of Vitamin A for High Risk Children

Diagnosis Preparation per capsule Vit. A Dosage & Schedule of

Administration
Measles 100,000 IU for infants Give one capsule upon
6-11 months old diagnosis regardless of
200,000 IU for children when the last dose of
12-71 mos. old vitamin A capsule (VAC)
was given
Severe pneumonia, 100,000 IU for infants Give one capsule upon
persistent diarrhea or 6-11 months old diagnosis, except when the
malnutrition 200,000 IU for children child was given VAC less
12-71 mos. old than 4 weeks before
diagnosis
Cases with 100,000 IU for infants Give one capsule
Xerophthalmia,incldg. 6-11 mos old Immediately upon
night blindness, Bitot’s 200,000 IU for children diagnosis. Give one
spots, corneal xerosis, 12-71 mos. old capsule the next day, and 1
 corneal ulcerations, capsule 2 weeks after.
and keratomalacia

COLUMN 8 – ANEMIC CHILDREN GIVEN IRON SUPPLEMENTATION – On the first column,

write the age in months of the sick children followed by the date started iron and date
completed.

COLUMN 9 – DIARRHEA CASES – Write the age in months of the sick children followed by the
dates ORT, ORS and ORS with zinc was given.

27
COLUMN 10 – PNEUMONIA CASES – Write the age in months of the sick children followed by
the date antibiotic treatment was given.
.

COLUMN 11 – REMARKS – Write other data of importance to child care.

3. Summary Tables:
The Summary Tables is a form with 12-month columns retained at the facility (BHS) where the
midwife records monthly all relevant data. The Summary Table is composed of: (1) Health
Program Accomplishment (2) Morbidity Diseases.

a. Health Program Accomplishment – the midwife records on this summary table all the data
that are found in the TCL. This summary table is an easy source of data for reports being
prepared by the Midwife. It would be wise to keep this updated as this can serve as proof of
accomplishments to show LGU officials whenever they visit the facility. This also serves as the
data source for any survey, special study, or research that may include thefacility. Most
importantly, this can serve as a tool for the midwife to assess her own accomplishments.

b. Morbidity Diseases – the midwife in the BHS accomplish this table on a monthly basis. This
summary table can also be the source of ten leading causes of morbidity for the
municipality/city. This summary table will help the nurse and MHO to get the monthly trend
of diseases.

The Summary Tables are intended to record data in the facility to facilitate the capture and
recall of data.

Summary Table – Health Program Accomplishments

The Summary Table – Health Program Accomplishments is a health facility based document
which records the performance of the BHS per month for one year, is filled up by the
midwife, and is her source of data for the Monthly Form. The table has provision for
quarterly totals which should be equivalent to the quarterly total of the PHN in her
Consolidation Table. The quarterly totals are also provided in this Summary Table so that
the midwife can already make preliminary analysis of her performance using these data.

Filling up the table

The first column lists exhaustively the indicators of your health service delivery in the
BHS. The next column is the “Target” column where you will place, at the start of the
year, the targets of your BHS for each Indicator. Please consult your PHN for the figure
you will enter in this column. Under each succeeding monthly columns, record the
number being asked that corresponds to each indicator for the month. Under each
quarter, write the totals required.

Summary Table – Morbidity Diseases

The Summary Table – Morbidity Diseases records all the diseases that occur for the entire
year. The diseases are recorded on a monthly basis and by age and sex. This Summary Table
shall also be the source of data for the Annual Report 2 – Morbidity Diseases Report.
 Filling up the table
On the Summary Table – Monthly Morbidity Diseases, write on the space provided the
month, the name of disease and the number of cases per disease and per age and sex.

4. Monthly Consolidation Table:

The Consolidation Table is an essential form in the FHSIS where the nurse at the RHU
records the reported data per indicator by each BHS or midwife. This is the source
document of the nurse for the Quarterly Form. The Consolidation Table shall serve as
the Output Table of the RHU as it already contains listing of BHS per indicator.

The Monthly Consolidation Table is a health facility-based document in which the PHN records
the report of the midwives in the municipality. At the end of every quarter, the PHN get the
totals of the different indicators to fill-up the Quarterly form for submission to the PHO.

Write the month and year which corresponds to the Monthly Report of each BHS. The first
column lists the indicators/diseases in the Monthly Form. On the succeeding column, write
the name of each BHS on top and the corresponding monthly data of each BHS.

THE MONTHLY FORM FOR PROGRAM REPORT (M1):

The Monthly Form is the reporting form that the midwife fills up to report her
accomplishments from the first day to the last day of the month and submits to the nurse at
the RHU/MHC for consolidation. Spaces are left blank for those indicators the
municipality/city needs to generate at their level.

a. Heading
Fill up the data asked for in the heading: the Month being reported and the Year,
the complete names of the BHS, the Municipality or City, Province and the Projected
Population.

MATERNAL CARE


Pregnant women with 4 or more prenatal visits – write on the space provided the total
number of pregnant women who had 4 or more prenatal visits during the
month/quarter such that at least one visit occurs during the first trimester, one during
the second trimester and at least 2 visits during the third trimester.

 Pregnant women given 2 doses of Tetanus Toxoid – write on the space provided the total
number of pregnant women given 2 doses of Tetanus Toxoid during the month/quarter.

 Pregnant women given TT2 plus – write on the space provided the total number of
nd rd th
pregnant women given TT2 plus during the month/ quarter. TT2 plus includes 2 , 3 , 4
th
and 5 doses of Tetanus Toxoid given to pregnant women.
 Pregnant women given complete iron with folic acid supplementation – write on the
space provided the total number of pregnant women given complete tablet of 60 mg
of Fe with 400 mcg Folic acid, once a day for 6 months or 180 tablets. The iron tablets
referred to are those given for free to the mother by the RHUs and BHSs and do not
include prescribed iron tablets. Iron tablet should be given as soon as pregnancy was
diagnosed. If the pregnant women did not take full course of the 180 tablets, she will
not be included in the report.

 Pregnant women given Vitamin A supplementation – write on the space provided the
total number of pregnant women given Vitamin A supplementation. Vitamin A
supplementation refers to 1 capsule/tablet of 10,000 I.U. twice a week to start from
th
the 4 month of pregnancy until delivery.


Post partum women with at least 2 post-partum visits – write on the space provided the
total number of post-partum women who were seen by the midwife/PHN/MHO at home or at the
clinic twice or more than twice after delivery such that first visit
should be within 24 hours upon delivery and the second visit within one week
after delivery.


Post partum women given complete iron supplementation – write on the space
provided the total number of post-partum women given complete tablet of 60 mcg of
Fe with 400 mcg Folic acid, once a day for 3 months or a total of 90 tablets. If
postpartum mother did not take full course of 90 tablets, she will not be included in
the report.

 Post partum women given Vitamin A supplementation – write on the space provided the
total number of post-partum or lactating women given 200,000 I.U. of Vitamin A capsule
within 4 weeks after delivery.

 Post partum women initiated breastfeeding within 1 hour after delivery – write on the
space provided the total number of post-partum or lactating women who initiated
breastfeeding within 1 hour after giving birth. .

FAMILY PLANNING

Current Users – write on the space provided the total number of FP clients who have
been carried over from the previous month after deducting the drop-outs of the
present month and adding the new acceptors of the present month. This consists of
CU for pills, IUD, injectables, condom, NFP (BBT, CM, STM, SDM and LAM) Female STR
and Male STR.

(Note: In preparing the quarterly report for this portion, the nurse at the RHU/MHC shall
consolidate only the data of the third month of the quarter.)

Formula:
Current users from the previous month (Jan) - 21
- Drop-outs present month (Feb) - - 2
+ Acceptors (New + Other) present month (Feb) - +6
= Current Users ending month of Feb - = 25
• New Acceptors – write on the space provided the number of clients who are using a family
planning method for the first time or a client who has never accepted any modern
family planning method at any clinics before (new to the program). It includes new
acceptors for pills, IUD, injectables, condom, NFP (BBT, CM, STM, SDM, and LAM)
Female STR and Male STR.

• Other Acceptors – write on the space provided the number of clients who are Changed
Method, Changed Clinic and Restart.

• Drop-outs – write on the space provided the number of clients who drop-out during the
month/quarter due to pregnancy, desire to become pregnant, medical

complications, fear of side effects, changed clinic, husband disapproves, menopause, lost or
moved out of the area or residence, failed to get supply, IUD expelled and other reasons.

CHILD CARE

 Immunization by antigen (BCG, DPT1 to DPT3, OPV1 to OPV 3, Hepatitis B2 to B3 and

anti-Measles vaccine) – write on the space provided the total number of infants 0-11
months who were given the specific antigen during the month/quarter.

 Infant given Hepatitis B1 within 24 hours after birth – write on the space provided the
total number of infants given Hepatitis B1 within 24 hours after birth during the
month/quarter.

 Infant given Hepatitis B1 more than 24 hours after birth – write on the space provided
the total number of infants given Hepatitis B1 more than 24 hours after birth during the
month/quarter.

 Fully Immunized Child – write on the space provided the total number of children 0-11
months who completed their immunization schedule during the month/quarter. To be
fully immunized, the child must have been given BCG, 3 doses of DPT, 3 doses of OPV,
3 doses of HepaB and one dose of anti-measles vaccine before reaching 1 year of age.
The child is counted as FIC as soon as all the required vaccines are administered
without waiting for the child to reach 1 year of age.

 Completely Immunized Child (12-23 mos) – write on the space provided the total
number of children 12-23 months of age who completed their immunization schedule
during the month/quarter. To be completely immunized, the child must have been
given BCG, 3 doses of DPT, 3 doses of OPV, 3 doses of HepaB and one dose of anti-
measles vaccine.

 Child Protected at Birth (CPAB) – write on the space provided the total number of
children whose (1) Mother has received 2 doses of TT during this pregnancy, provided
TT2 was given at least a month prior to delivery, or (2) Mother has received at least 3
doses of TT anytime prior to pregnancy with this child.

 Infants 6 months of age seen - write on the space provided the total number of infants seen
th
at 6 month at the facility or during home visit.
 Infants exclusively breastfed until 6 months - write on the space provided the total
th
number of infants seen to be exclusively breastfed from birth up to 6 months.
Exclusively breastfeeding is giving no other food (including water) other than breast
milk. Drops of vitamins and prescribed medication (by doctor only) given while
breastfeeding is still “exclusive BF”.

 Infant referred for newborn screening - write on the space provided the total number
of

infants given referral for newborn screening.

 Infant 6-11 months old given Vitamin A - write on the space provided the total
number of infants 6-11 months old given Vitamin A Supplementation. Vitamin A
supplementation refers to 1 dose of 100,000 I.U. One capsule is given anytime during
the 6-11 months but usually given at 9 months during the measles immunization.

NOTE: Vitamin A given during Garantisadong Pambata should not be included in this
report.

 Children 12-59 months old given Vitamin A - write on the space provided the total
number of children 12-59 months old given Vitamin A Supplementation.Vitamin A
supplementation refers to 200,000 I.U. Dosage and duration is 1 capsule every six
months.

NOTE: Vitamin A given during Garantisadong Pambata should not be included in this
report.

 Children 60-71 months old given Vitamin A - write on the space provided the total
number of children 60-71 months old given Vitamin A Supplementation.Vitamin A
supplementation refers to 200,000 I.U. Dosage and duration is 1 capsule every six
months.

NOTE: Vitamin A given during Garantisadong Pambata should not be included in this
report.

 Sick Children 6-11, 12-59 and 60-71 months old seen - write on the space provided the
number of sick children whose ages ranges from 6 to 11 months, 12-59 months and
60-71 months old seen during the month/quarter. High Risk or Sick Children are those
with the following categories: (1) severe pneumonia (2) persistent diarrhea (3)
measles (4) under nutrition and (5) Cases with Xerophthalmia, including night
blindness, Bitot’s spots, corneal xerosis, corneal ulcerations and keratomalacia

 Sick Children 6-11 months old given Vitamin A - Write on the space provided the
number of sick children whose ages ranges from 6 to 11 months and were given
Vitamin A during the month/quarter. Dosage of Vitamin A for 6-11 months old infants
is 100,000 IU.

NOTE: Vitamin A given during Garantisadong Pambata should not be included in this
report.
 Sick Children 12-59 months old given Vitamin A Capsule- write on the space provided
the number of sick children whose ages ranges from 12 to 59 months old and were
given Vitamin A capsule during the month/quarter. Dosage of Vitamin A for 12-59
months old children is 200,000 IU (1 capsule every 6 months).

NOTE: Vitamin A given during Garantisadong Pambata should not be included in this
report.

 Sick Children 60-71 months old given Vitamin A Capsule- write on the space provided
the number of sick children whose ages ranges from 60 to 71 months old and were
given Vitamin A capsule during the month/quarter. Dosage of Vitamin A for 60-71
months old infants is 200,000 IU. Dosage of Vitamin A for 12-59 months old children is
200,000 IU (1 capsule every 6 months).

NOTE: Vitamin A given during Garantisadong Pambata should not be included in this
report.

 Infant 2-6 months old with low birth weight - write on the space provided the
number of infant whose ages ranges from 2 to 6 months old with low birth weight
seen during the month/quarter. Low birth weight (LBW) Infant refers to infant with
birth weight less than 2.5 kilograms or 2,500 grams.

 Infant 2-6 months old with low birth weight given iron supplements - write on the
space provided the number of infant whose ages ranges from 2 to 6 months old with
low birth weight and was given iron during the month/quarter. Dosage is 0.3 ml once
a day to start at two months of age until 6 months when complementary foods are
given. (Preparation is 15 mg. elemental iron/0.6 ml)

 Anemic Children 2-59 months old seen - write on the space provided the number of
anemic children whose ages ranges from 2 to 59 months old seen during the
month/quarter.

 Anemic Children 2-59 months old seen given iron supplements - write on the space
provided the number of anemic children whose ages ranges from 2 to 59 months old
and was given iron supplementation during the month/quarter. Dosage is 1 tsp. once
a day for 3 months or 30 mg. once a week for 6 months with supervised
administration.

 Diarrhea cases 0-59 months old seen - write on the space provided the total number of diarrhea
children 0-59 months old seen during the month/quarter.

 Diarrhea cases 0-59 months old given ORT - write on the space provided the total
number of diarrhea children whose ages ranges from 0 to 59 months old and was
given ORT during the month/quarter. Oral Rehydration Therapy includes other
hydrating fluids other than ORS.

 Diarrhea cases 0-59 months old given ORS - write on the space provided the total number
of diarrhea children whose ages ranges from 0 to 59 months old and was given ORS during
the month/quarter.
 Diarrhea cases 0-59 months old given ORS with zinc - write on the space provided the

total number of diarrhea children whose ages ranges from 0 to 59 months old and was
given ORS with zinc during the month/quarter. Dosage for children less than 6 months
is 10 mg. elemental Zn/day and for children more than 6 months is 20 mg elemental
Zn/day x 10-14 days.

 Pneumonia cases 0-59 months old seen - write on the space provided the total number of children
0-59 months old seen with pneumonia during the month/quarter.

 Pneumonia cases 0-59 months old given treatment - write on the space provided the
total number of children 0-59 months old seen with pneumonia and was given antibiotic
treatment during the month/quarter.

Diseases Control:

Tuberculosis:

• TB symptomatics who underwent Direct Sputum Smear Microscopy (DSSM) – write on the
space provided the total number of person who present symptoms or signs suggestive
of TB, in particular cough or long duration (2 or more weeks of cough).

• Smear positive (+) discovered – write on the space provided the number of patient with the
following: (1) at least 2 sputum specimens positive for Acid Fast Bacilli (AFB) on direct
sputum smear microscopy with or without radiographic abnormalities consistent with
active TB; or (2) with one sputum specimen positive for AFB and with
radiographic abnormalities consistent with active TB as determined by clinician ; or
(3) with one sputum specimen positive for AFB with sputum culture positive of
Mycobacterium Tuberculosis (M.tb)

• New Smear (+) cases initiated treatment - write on the space provided the number of new
smear positive cases given treatment and registered in a DOTS facility. New smear
positive cases are TB patients that have not taken anti-TB drugs before or if they have
taken anti-TB drugs it is for less than 1 month.

• New smear positive cases cured –write on the space provided the number of new smear
positive cases who have completed treatment and is smear negative in the last month
of treatment and on at least one previous occasion in the continuation phase

• Smear positive re-treatment cases initiated treatment –write on the space provided the
number of smear positive re-treatment cases given treatment and registered in a
DOTS facility. Re-treatment cases refer to Relapse, Return after Default, Treatment
Failure and Other type of TB cases.

numberSmear positive re-treatment cases who got cured - write on the space provided the
of sputum smear positive (+) re- treatment patient who has completed treatment
and is now sputum smear negative (-) in the last month of treatment and

on at least one previous occasion in the continuation phase.

Leprosy:

 Leprosy Cases - write on the space provided the number of leprosy cases. Include both
multibacilliary (MB) and paucibacillary (PB).

 Leprosy Cases below 15 years of age - write on the space provided the number of leprosy
cases below 15 years of age. Include both multibacilliary (MB) and paucibacillary (PB).

 Newly Detected Leprosy Cases - write on the space provided the number of newly detected leprosy
cases. Include both multibacilliary (MB) and paucibacillary (PB).

 Newly Detected Leprosy Cases with Grade 2 disability - write on the space provided the n
umber of newly detected leprosy cases with Grade 2 disability. Include both multibacilliary
(MB) and paucibacillary (PB).

 Cases Cured - write on the space provided the number of leprosy cases who have received
a complete treatment. For PB patients 6 blister packs and for MB patients 12 blister packs.

Malaria:

• Malaria case among less than 5 years of age and above 5 years of age – write on the
space provided the total number of malaria cases among less than 5 years of age and
above 5 years of age.

• Cofirmed malaria cases by species: P.falciparum, P.vivax, P.malariae and P.ovale – write
on the space provided the total number of malaria cases by species by sex and
pregnant women.(P. falciparum, P.vivax, P.malariae and P.ovale).

• Cofirmed malaria cases by method: Slide and Rapid Diagnostic Test (RDT) – write on the
space provided the total number of malaria cases by method (slide and RDT).

• Households at risk – write on the space provided the total number of households at risk
of malaria.

• Households given Insecticide Treated Nets (ITN) – write on the space provided the total
number of householdsgiven insecticide treated nets.

Schistosomiasis:
 Symptomatic Case - write on the space provided the number of schistosomiasis cases.

 Positive Case - write on the space provided the number of schistosomiasis cases found
positive.

 Case examined with low, medium and high intensity - write on the space provided the number of
schistosomiasis cases with low, medium and high intensity.
 Cases treated - write on the space provided the number of schistosomiasis cases treated.
Treatment of cases is the administration of Praziquantel, 600 mg given just one day in 2-3
divided doses at 40-60 mg/kg.

 Casesreferred
referred to hospital facilities - write on the space provided the number of schistosomiasis cases
to hospital facilities.

Filariasis:
 Case examined - write on the space provided the number of blood smears examined.

 Case positive (+) - write on the space provided the number of blood smears positive for
microfilariae which includes old and new cases.

 Adenolymphangitis Cases - write on the space provided the number of lymphedema

cases.

Person given Multi-Drug Administration - write on the space provided the number of persons given
Multi-Drug Administration.

 Microfilaria Density (MFD) in the slides found positive (+) - write on the space provided the total
count of mf in the slides found positive.

THE MONTHLY REPORT OF MORBIDITY DISEASES (M2):

The Monthly Report of Morbidity Diseases contains a list of all diseases by age and sex. It
summarizes the monthly report of morbidity diseases. The Midwife forwards this report to
the PHN at the RHU/MHC.

a. Heading
Write the full name of the BHS/BHC, RHU/MHC. the month
and the year for which the report is being prepared.

b. Filling up the report

List all diseases encountered in your area and for each disease write on the space
provided the month total number of males (M) and females (F) for the corresponding
age grouping.

THE QUARTERLY FORM FOR PROGRAM REPORT (Q1):

The Quarterly Form is the official health report of the municipality/city for the quarter. It
contains the consolidated three month reports of all the BHSs and the RHU/MHC for health
service delivery during the quarter. The PHN forwards this report to the Provincial FHSIS
Coordinator at the PHO every third week of the first month of the succeeding quarter for
provincial consolidation. The municipality/city prepared only one quarterly report. In case
there is more than one RHU/MHC in the municipality/city, the MHO/CHO who sits as the vice
chairman of the LHB shall be responsible for directing the consolidation of all the quarterly
data from different RHUs/MHCs and the preparation of one Quarterly Form for the
municipality/city. Spaces are left blank for those indicators the municipality/city wants to
generate based on their local needs and interests.

a. Heading
Fill up the heading with the data being asked for: Identify the Quarter and Year.
Place full name of the Municipality/City and the Province to which the LGU belongs.

Projected Population for the year – write on the space provided the city or
municipality population.

b. Filling up the form

The Quarterly Form is designed by program with the indicators listed in the first
column, followed by the eligible population, number of male and female cases, the
total for both sexes, the percentage accomplishment, the interpretation or analysis of
data and recommendations or actions taken by your area. Denominators for some
indicators are listed below for easy computation. All indicators found in the Monthly
Form should have the same definitions except for Dental Health which can only be
found in the Quarterly Form.

DENTAL HEALTH

childrenOrally Fit Children 12-71 months old - write on the space provided the number of
whose ages ranges from 12 to 71 months old and meet all of the following upon
oral examination: (1) caries-free or decayed teethy filled (2) has healthy gums
(3) no oral debris and (4) no dento-facial anomaly that limits normal function.

 Children 12-71 months old provided with Basic Oral Health Care (BOHC) - write on the
space provided the number of children whose ages ranges from 12 to 71 months old
and were provided with Basic Oral Health Care during the quarter. Basic Oral Health
Care refers to one of more of the following services: (1) Oral Examination (2) 80%
Attendance to Supervised Tooth Brushing (3) Atraumatic Restorative Treatment (ART)
and (4) Oral Urgent Treatment (OUT) which includes removal of unsavable teeth or
referral of complicates cases of treatment of post-extraction complications
or drainage of localized oral abscess.
 Adolescent and Youth (10-24 years old) provided with Basic Oral Health Care (BOHC)
- write on the space provided the number of youth and adolescents whose ages ranges
from 10 to 24 years old and were provided with Basic Oral Health Care during the
quarter. Basic Oral Health Care refers to one of more of the following services:
(1) Oral Examination (2) Education and counseling on health effects of
tobacco/smoking, diet and oral hygiene.

 Pregnant women provided with Basic Oral Health Care (BOHC) - write on the space
provided the number of pregnant women who were provided with Basic Oral Health
Care during the quarter. Basic Oral Health Care refers to one of more of the following
services: (1) Oral Examination (2) Scaling (3) Permanent Filling and (4) Gum Treatment.
 Older Persons 60 years old and above provided with Basic Oral Health Care (BOHC) -
write on the space provided the number of older persons ages 60 years old and above
who were provided with Basic Oral Health Care during the quarter. Basic Oral Health
Care refers to one of more of the following services: (1) Oral Examination (2)
Extraction and (3) Gum Treatment.

THE QUARTERLY CONSOLIDATION REPORT OF MORBIDITY DISEASES

(Q2):

The Quarterly Report of Morbidity Diseases contains a list of all diseases by age and gender. It
summarizes quarterly of diseases that are reported in the municipality/city for which the PHN
is responsible. The PHN forwards this report to the Provincial FHSIS Coordinator at the PHO
every third week of the first month of the succeeding quarter for provincial consolidation.

a. Heading
Fill the Year for which the report is being prepared. Write the full name of the
Municipality/City and Province and the quarter.

b. Filling up the report

Write in the space provided the disease name, the quarter total number of males
(M) and females (F) for the corresponding age grouping reported for the particular
disease. Data for the quarterly consolidation come from the Monthly Report of the
Midwife and data found in the RHU.

THE ANNUAL FORMS:

Annual BHS Report ( A-BHS)

The Annual BHS Report Form contains basic information about the BHS which are submitted
only once year. It consists of data categorized under demographic, environmental and
natality. The midwife in the BHS fills-up the form and submits to the RHU/MHC for
consolidation.
 a. Heading
Fill in the required information for the Year, complete name of the BHS,
municipality/city and the province.

b. Filling up the form.

For Demographic Profile, write the population, number of barangays and
households. The indicators are the same with those found in the Annual Form 1 and
same definitions must be followed.

Annual Form 1 – Vital Statistics Report (A1-RHU)

The Annual Form contains basic information about the municipality or city which is being
submitted only once a year. It consists of data categorized under demographic,
environmental, natality and mortality. The nurse in the RHU/MHC fills up the form and
submits to the PHO for computer processing.

a. Heading
Fill in the required information for the Year, complete name of the RHU and province.

b. Filling-up the form

The Annual Form consists of the program indicators listed in the first column, followed
by the number, the percentage accomplishment or ratio/rate, the interpretation or
analysis of data and the recommendations or action taken by your area. To facilitate
computation of rates/ratios, denominators for some indicators are listed below.

Demographic Information

 No. of Barangays – write on the space provided the actual number of barangays
within the municipality/city.


No. of BHSs – write on the space provided the actual number of barangay health
stations. A BHS can be considered a reporting unit if the following
conditions are satisfied:

a. It renders/delivers health services to a defined catchment area which

may be composed of one or more barangays.
b. A midwife renders regular service to the area. In cases where the
midwife of the area is in prolonged leave of absence or resigned but a
replacement is expected, the BHS is still remains a reporting unit. The
reports will be expected to be submitted by the nurse (2) or midwife(s)
who took over the servicing of the area.
c. Health services may be provided from any physical structure designated
for the purpose i.e. a BHS building, a barangay hall or a place of
residence.
d. The catchment area served is not a service area of any RHU. For
instance, Poblacion in most cases is the catchment area served by the
 RHU. Thus, Poblacion BHS cannot be considered a reporting unit. The
reports of this BHS should be prepared and submitted by the RHU.
e. It should not include satellite BHS which are visited by the midwife but
part of the catchment of the “mother” BHS.

 No. of Health Workers in LGU – this includes nationally paid public

health workers and those hired by the local government. Write on the
space provided the total number of doctors, dentists, nurses, midwives,
nutritionists, medical technologists, engineers, sanitary inspectors and
active BHWs.

NOTE: Hospital personnel are not included in this indicator.

Environmental
 No. of Households (HH) – write on the space provided the actual number
of households in the municipality. The data should be based on actual
household survey within the locality.

 Households with access to improved or safe water supply – write on the space
provided the number of households covered by or have access to the following
types of drinking water sources that conform to the Philippine National
Standards for Drinking Water (PNSDW) (i.e., free from bacterial, chemical,
physical and other contaminants):
 Level I (Point Source) – A protected well (shallow and deep well) improved
dug well, developed spring, rainwater cistern with an outlet but
without distribution system.

Level II (Communal Faucet System or Standpost) – refers to a system

composed of a source, a reservoir, a piped distribution network, and a
communal faucet located not more than 25 meters from the farthest
house. It is generally suitable for rural and urban areas where houses
are clustered densely enough to justify a simple piped water system.

Note: For reporting purposes Level II system may also include a communal
faucet connected to Level III where group of households get their water
supply.

Level III (Waterworks System) – A system with a source, transmission pipes,

a reservoir, and a piped distribution network for household taps. It is
generally suited for densely-populated areas. Examples of these are
MWSS and water districts with individual household connections.

Note: For reporting purposes of Level III system may also include a Level I
system with piped distribution for household tap serving individual or group
of housing dwellings such as apartments or condominiums.

 Households with sanitary toilet facilities – write on the space provided the
total number of households with sanitary toilets. This refers to households
with flush toilets connected to septic tank and/or sewerage system or any
other approved treatment system, sanitary pit latrine or ventilated improved
pit latrine.

 Households with satisfactory disposal of solid waste – write on the space

provided the total number of households with garbage disposal through
composting, burying, city/municipal system storage, collection and disposal.

 Households with complete basic sanitation facilities – write on the space

provided the total number of households which satisfy the presence of the
following basic sanitation elements, namely: access to safe water, availability
of a sanitary toilet and satisfactory system of garbage disposal.

 Food Establishments – write on the space provided the total number of food
establishments which includes restaurants, sari-sari stores, canteens, coffee
shops, carinderia, refreshment parlors, bakeries, and water refilling stations,
food manufacturing, bottling, dairy and canning establishments.

 Food Establishments with Sanitary Permit – write on the space provided the total
number of food establishments with sanitary permit.

 Food Handlers – write on the space provided the total number of food handlers
employed in food establishments
  Food Handlers with Health Certificates – write on the space provided the total number
of food handlers with health certificates.

 Salt Samples Tested – write on the space provided the number of salt samples
tested.

 Salt Samples Tested found (+) for iodine – write on the space provided the
number of salt samples tested and found positive for iodine.

Natality
 No. of live births
Male – write on the space provided the total number of males who
were born alive in the municipality/city.
Female – write on the space provided the total number of females who were
born alive in the municipality/city.

 Weight at birth

2,500 gms and greater – write on the space provided the total number of live
births with weights equal to or greater than 2,500 grams.
Less than 2,500 gms – write on the space provided the total number of live
births with weights less than 2,500 grams.
Not known – write on the space provided the total number of live
births whose weights at birth are not known.

 Deliveries Attended by:

Doctors – write on the space provided the number of deliveries attended by

doctors.
Nurses – write on the space provided the number of deliveries attended by
nurses.
Midwives – write on the space provided the number of deliveries attended
by midwives.
Trained Hilot/TBA – write on the space provided the number of births
attended by trained hilot or health worker not mentioned above.
Others – write on the space provided the number of births attended by those
other than the above mentioned.

 Deliveries by Type:
Normal – write on the space provided the number of livebirths by normal
spontaneous delivery (NSD).
Others – write on the space provided the number of livebirths
delivered other than NSD.

 Deliveries by Place:

Home – write on the space provided the total number of livebirths that were
delivered at home.
 Hospital – write on the space provided the total number of livebirths that
were delivered in government or private hospitals and clinics.
Others – write on the space provided the total number of livebirths that were
delivered in places other than the home, private hospital and
clinics and government hospitals.

 Birth by type of pregnancy:

Normal – write on the space provided the total number of pregnancy that is
classified as normal.
Risk – write on the space provided the total number of pregnancy that are
classified as risk pregnancy.
Unknown – write on the space provided the total number of pregnancy that
are not classified under risk or normal pregnancy.
Mortality
 Deaths by sex:
Male – write on the space provided the total number of male deaths
Female – write on the space provided the total number of female deaths

 Infant Mortality – write on the space provided the total number of

infant deaths.

 Maternal Mortality – write on the space provided the total number of

pregnant women who died due to causes related to pregnancy,
childbirth and puerperium.

 Deaths due to Neonatal Tetanus – write on the space provided the total number of
deaths 3 to 28 days of age due to tetanus neonatorum.

 Perinatal Deaths – write on the space provided the total number of fetus who
died from 22nd week of gestation (the time when birth weight is normally
500mg) and ends 7 completed days after birth.

 Under Five Mortality – write on the space provided the total number of deaths among
children under five years of age.

Annual Form 2 – Morbidity Disease Report

This report is prepared by the PHN as the annual consolidation of the monthly and quarterly
morbidity disease reports from the BHSs and the RHUs. The Source of this report is the
Summary Table. The report consists of all reported causes of morbidity diseases with age
and sex breakdown, and submitted to the PHO.

Annual Form 3 – Mortality Report

This report is the annual consolidation of all deaths occurred in your area. The Source of this
report is the Summary Table. The PHN who prepares this report breaks down the number
reported in each disease by age and gender.