Republic of the Philippines

CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
centralluzon.doh.gov.ph
MONTHLY CXR VOUCHER SUMMARY REPORT
City Health Center V - Mapalacsiao

No. Indicator Adult (15 y/o and Child (14 y/o and
above) below)
Male Female Male Female
SCREENING
1 Number of Patients Referred to CXR Provider

2 Number of Patients who AVAILED free Xray

3 Number of Screened with (+) X-ray Result
DIAGNOSIS (TESTING)
4 Total no. Tested on Xpert MTB/Rif
5 No. of FINAL Xpert MTB/Rif Result: MTB NOT Detected;
Rifampicin Resistance NOT Detected (N)
6 No. of FINAL Xpert MTB/Rif Result: MTB Detected, Rifampicin
Resistance NOT Detected (T)

7 No. of FINAL Xpert MTB/Rif Result: MTB Detected, Rifampicin

Resistance INDETERMINATE (TI)

8 No. of FINAL Xpert MTB/Rif Result: MTB Detected, Rifampicin

Resistance DETECTED (RR)
ENROLLMENT TO TB TREATMENT
9 BC DSTB Cases enrolled
10 CD DSTB Cases enrolled
11 BC RRTB Cases enrolled
ENROLLMENT TO TB PREVENTIVE TREATMENT
12 No. of Contact traced from BC patients
13 No. of Contact traced from CD patients
14 No. of Contacts screened with X-ray or symptoms
15 TPT Cases enrolled
16 No. of TB Cases Notified from Contacts
PENDING
17 Xpert MTB/Rif Testing
18 BC DSTB Cases Enrollment
19 CD DSTB Cases Enrollment
20 BC RRTB Cases Enrollment
21 TPT Cases Enrollment
Remarks: Pending Testing Remarks: Pending Enrollment Remarks: (if previously screened but enrolled in
Unable to locate- Unable to locate- the current month, please provide breakdown)
Unable to expectorate- Unable to expectorate- BC DSTB –
Refused- Refused- CD DSTB –
Died- Died- BC DRTB –
TPT -

Prepared by: Maria Emelia M. Soberano, RN