Scribd
Upload
429 views1 page

F4A Hospital Out-Patient Monthly Report Form

This document is a monthly malaria report form for a hospital outpatient facility. It collects information on malaria tests conducted, including the name of the patient, test result, diagnostic code, and remarks. Totals are provided for the number of slides examined, rapid diagnostic tests done, and positives detected. It also collects the number of patients tested negative for malaria within 24 hours and those given a clinical diagnosis. The form is to be prepared by a designated hospital staff member and submitted to the appropriate local and provincial health offices.

Uploaded by

Cha Tuban Diana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
429 views1 page

F4A Hospital Out-Patient Monthly Report Form

This document is a monthly malaria report form for a hospital outpatient facility. It collects information on malaria tests conducted, including the name of the patient, test result, diagnostic code, and remarks. Totals are provided for the number of slides examined, rapid diagnostic tests done, and positives detected. It also collects the number of patients tested negative for malaria within 24 hours and those given a clinical diagnosis. The form is to be prepared by a designated hospital staff member and submitted to the appropriate local and provincial health offices.

Uploaded by

Cha Tuban Diana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Philippine Malaria Information System Form: A blank form for hospital outpatient monthly malaria reporting, capturing details like patient name, slide number, results, and remarks.

Philippine Malaria Information System (PhilMIS)

F4a

Hospital Out-Patient Monthly Malaria Report Form (HOMMRF)

MONTH AND YEAR


NAME OF FACILITY
PROVINCE
MUNICIPALITY
BARANGAY
DATE SUBMITTED
SUBMITTED TO

NAME OF PATIENT

REPORT NO.
(To be filled-up by Data Encoder)

SLIDE/RDT
NO.

RESULT

ICD 10

REMARK(S)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
NO. OF SLIDES EXAMINED :
NO. OF RDT DONE :
NO. OF POSITIVES:

NO. OF PATIENT TESTED


NEGATIVE FOR MALARIA
WITHIN 24 HOURS

NO. OF CLINICAL DIAGNOSIS:


PREPARED BY:
DESIGNATION:
RECEIVED IN THE RHU BY :

REVIEWED IN THE RHU BY:

POSITION:
DATE RECEIVED:
RECEIVED IN THE PHO BY: (IF APPLICABLE)
POSITION:
DATE REVIEWED:

REVIEWED IN THE PHO BY: (IF APPLICABLE)

You might also like