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PHEM Report

This document contains two weekly disease report forms used by health facilities and health extension workers in Ethiopia to report outpatient and inpatient disease cases and deaths on a weekly basis. The forms collect data on common diseases like malaria, meningitis, dysentery, typhoid, malnutrition and immediately reportable diseases. They also collect information on the timeliness and completeness of reporting. The health facility form collects more detailed disease-specific data while the health extension worker form focuses on common diseases identified at the community level. Both forms analyze trends, abnormal increases, and recommend actions to address issues.

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mekuria
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165 views

PHEM Report

This document contains two weekly disease report forms used by health facilities and health extension workers in Ethiopia to report outpatient and inpatient disease cases and deaths on a weekly basis. The forms collect data on common diseases like malaria, meningitis, dysentery, typhoid, malnutrition and immediately reportable diseases. They also collect information on the timeliness and completeness of reporting. The health facility form collects more detailed disease-specific data while the health extension worker form focuses on common diseases identified at the community level. Both forms analyze trends, abnormal increases, and recommend actions to address issues.

Uploaded by

mekuria
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Weekly disease report form out patient and in patient cases and deaths (WRF )

Health facility name TOMBE HEALTH CENTER Woreda


and type
Zone w/showa Region Oromia
Start of week from Monday ____________________________ to Sunday ______________________ day /month /year in Ethiopia
calendar (day month year )
1. Record below the total number of cases and death for each disease/condition for the current week

Indicator Out patient In patient


cases Cases deaths
Total malaria (confirmed and clinical )
Total malaria suspected fever case examined by RDT or microscopy
Number or cases positive for P.Falciparum
malaria parasites (ether by RDT or P.Vivax
microscopy)
Meningitis
Dysentery
Typhoid fever
Relapsing fever
Epidemic typhus
Sever Acute Malnutrition/MUAC <11cm and /or bilateral Edema in
under 5Year children (new cases only)
RDT=Rapid Diagnostic Test MUAC =Mid upper arm circumference

2. Report timeliness and completeness (to be filled only by woreda health office and zone /Regional Health Bureaus)

Indicator Government NGO Private clinic


H.post H.C Hospital
No of sites that are supposed to report weekly
No of sites the report on time
3. Summary for Immediately Reportable case based disease /Condition (Total cases and deaths reported on case based
forms or line lists during the report week )

Disease C D Disease C D Disease C D


AFP/polio Maternal Death SARS
(Confirmed)
Anthrax Small pox measles
Cholera Neonatal tetanus
V/hemorrhagic fever
Dracunculiasis (guinea Yellow fever Pandemic influenza
worm )
Deaths of women of Rabies Others specify ________________
reproductive age (15-
49)years
Maternal Death (Suspected) others specify
C=case ;D=death; SARS =severe acute respiratory syndrome NOTE:Official counts of immediately notified cases come
only forms or line lists

Look at the trends, abnormal increase in cases ,death or cases fatality ratios? Improving trends ? Action taken
and Recommendations
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Datesent by HF/woreda /Zone /region ____________________ Date received at woreda /zone/region -------------------
Sent by: ______________________________________ - Received by :------------------------------
Tele : __________________________ E-mail: -------------------------------- Tele: ----------------------------------- E.mail:----------------------------------

Weekly disease report form for health extension workers (WRF HEW )
Health post name Woreda
Kebele Zone
Start of week from Monday / / to Sunday / /
(day month year in Ethiopia calendar ) (day month year in Ethiopia calendar )

1. Record below the total number of cases and death for each disease/condition for the current
week

Indicator Total cases


Total malaria (confirmed and clinical )
Total malaria (confirmed by RDT +clinically diagnosed
as malaria)
Number or cases positive for malaria P.Falciparum
parasites (either by RDT or microscopy) P.Vivax

Meningitis(suspected)
Bloody diarrhea
Acute febrile illiness(other than malaria &meningitis )
Sever acute malnutrition/MUAC <11cm and /or bilateral
edema in under 5Year children (new cases only)
RDT=Rapid Diagnostic Test MUAC =Mid upper urm circumference

2. summary for immediately reportable case based disease /conditions:

Disease C D Disease C D Disease C D


AFP/polio Fever+Rash Haemorrhagic Diseases
Anthrax Neonatal Guinea worm
Tetanus
Deaths of women of
Acute Watery Influenza Like reproductive age (15-
Diarrhea Illiness 49)years
Rabies Other (specify) Other (specify)
C=case ; D=death

Look at the trends , abnormal increases in cases, improving trends ? Action taken &
Recommendations:

------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------

Date sent by HF/woreda /Zone /region ----/--------/----- Date received at woreda


/zone/region ------/-------/-------
Sent by -------------------------------------------- Received by
------------------------------
Tele ------------------------------ E -mail -------------------------------- Tele
----------------------------------- E.mail----------------------------------

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