192

182

195
193
191
185
183
181

194
190
189
188
187
186
184
Index

Others
New (D)

Summary
Relapse (Q)
Adult (G)

Adult (G)
Date

(A)

Contnuing (D)
Pregnant (G)
Male (F)

Posnaal (G)

Pregnant (G)
Posnaal (G)

Re-admissions (Q)
Female (F)

> 15 - 17 years (E)

dd/mm/yyyy

> 15 - 17 years (E)

prepared
(B)
Paten Unique Number

No. of patens seen:

by:
HIV Postve (R) HIV Negatve (R)

Name
Service Point:

Paten names

(C)

Page Summary Sheet and Reference Column:

Anaemia (U)
Anaemia (U)

Pregnant (G)
Pregnant (G)

Posnaal (G)

PosNaal (G)
HIV Positve (R)

HIV Negatve (R)

Adul/>15 - 17 Years (G)

Adul/>15 - 17 Years (G)
MoH407/ [MFL Code]: _______________________

Paten visi ype: 1=New, 2=Revisi

(D)

Severe
Severe

SAM (P)
SAM (P)
Age (in Years)
(E)
(F)

MAM (P)
Gender: M=Male, F=Female
Background Informaton

Nuritonal Diagnosis:

MAM (P)

Moderate
Moderate
Paten Caegory: 1=Adul/15years - 17 years,
(G)

Designation:
2=Pregnant, 3 = posnaal

Mild

Mild
Residence & Landmark
(H)

Normal

Normal
(I)

Telephone No

TB (T)
TB (T)
New (D)

On ARVs (S)
On ARVs (S)

Diarrhoea (T)
Diarrhoea (T)

Oher OI’s (T)

Oher OI’s (T)

Contnuing (D)
Weigh (Kg)
(J)

Date:
Adult/
>15 - 17
Edema: Y = Yes, N = No
(K)

Years (G)
ART and OI’s
Heigh (m)
(L )

(G)
Pregnant
BMI for Age (15-17 years)
(M)
Other:_________________

(G)
Posnaal
BMI (Adul over 18 years)
(N)

FBF

CSB
(O)

MUAC (Pregnan and posnaal women) (cm)

Ohers
Vitamin A
Prenatal

Posnaal Nuritonal Saus: 1= SAM, 2= MAM, 3= Overweigh, 4= Obese,

(P)

Iron & Folic Acid

5= Normal
For SAM/MAM patens: 1= 1s tme diagnosis, 2= Relapse,
(Q)

Maernal Nuriton (Z)

3= Readmission

Therapeutc die milk (F75)

Therapeutc die milk (F100)

(R)

Serostatus: P = Positve, N = Negatve

Nuriton Counselling (Z, AA)

Critcal Nuriton Practces (AA)

(S)

On ARVs: Y = Yes, N = No

Ready o Use Therapeutc Foods (RUTF)

Ready o Use Supplemenal Foods (RUSF)

Prescribed Nuriton Suppor (AB, AC,AD)

Co-existng conditons: 1 = TB, 2 = Diarrhoea, 3 = Oral hrush, 4=Oher

( T)

OI’s, 5 = Nausea/Vomitng/Anorexia 6=None

Assessmens and Nuritonal Diagnosis

17Yrs(G)
FACILITY DAILY REGISTER FOR NUTRITION SERVICES

Adul/>15-
HIVPositve(R)

Anaemia: 1- Severe, 2= Moderate, 3= Mild, 4= Normal, 5=Not done

( U)

Meabolic disorders: 1= Lypodysrophy, 2= Dyslipedemia, 3= Type

MINISTRY OF MEDICAL SERVICES/MINISTRY OF PUBLIC HEALTH

II Diabees, Wais Circumference: 4 = Male < 102cm, 5 Male >

( V)

102cm 6=Female < 88cm, 7=Female > 88cm, 8=Ohers, 9=None

Nuritonal Inerventon:

Pregnant(G)
HIVPositve(R)

Allergies and Intolerance: 1 = Food allergies(name food ...........),

( W)

2 = Food inolerance(name food ..............), 3 = None

CD4 coun: 1= <350, 2= 350 - 500, 3= > 500 (cells/mm3), 4=Not done
Posnaal(G)
( X)

HIVPositve(R)

Food Secure: 1=Yes, 2= No

( Y)

All(G)
HIVNegatve(R)

Maernal Nuriton: 1= Pre-naal, 2= Posnaal

( Z)

Critcal Nuriton Practces: 1= Nuriton saus assessmen

2= Dieery/Energy needs, 3= Saniaton, 4= Positve living behaviour,
Cured
(AA)

5= Exercise, 6= Safe drinking waer, 7= promp reamen for

OIs, 8= Drug food ineracton side effecs, 9 = None
Transferred
Discharged
Nuriton Counselling

Satc Weigh
Losing Weigh
Gaining Weigh
Tick
ADULT (15+ years)

Therapeutc foods: 1= RUTF, 2= F75, 3= F100, , 4=Resomol,

(AB)

5=Ohers, 6=None
Referrals and Transfers (AF)
Refused Nuriton Suppor
Nuritonal Inerventons

Referral for livelihood suppor

Supplemenal foods: 1= FBF, 2= CSB, 3= RUSF

4= Liquid nuriton Supplemens, 5=Ohers, 6=None
Referral o in-paten/oher clinics
or Enter Code

(AC )

Micronutrients: 1= Vitamin A, 2= B6, 3= Folic, 4= Mult Viamins

5= Iron, 6= Iron-Folae, 7=Zinc, 8= Multple micronuriens,
(AD)
Register Serial Number: [MOH/NASCOP

9 = Ohers (specify), 10=None

Prescribed Nuritonal Suppor

17Yrs(G)

Refer o paten card saus of contnuing SAM/MAM Patens

1= Gaining weigh, 2= Loosing weigh, 3= Satc Weigh, 4= Cured,
(AE )

5= Discharged, 6=Refused Nuriton Suppor

Outcomes

Outcomes and Referrals

Saus of contnuing SAM/MAM cliens (AE) Adul/>15- Pregnant(G)

HIVPositve(R) HIVPositve(R)

Referrals and Transfers: 1= Referral for inpaten care, 2= Referral

o oher clinics, 3= Referral for livelihood suppor (food insecure),
Number]

(AF )

4= Transferred, 5= Referred from oher facilites

Use a new page at the beginning of every month

Posnaal(G)
Follow up

TCA
(AG)
(dd/mm/yyyy)

All(G)

Clinician’s Designaton/ Inital: 1= Nuritonis, 2= Nurse, 3= Doctor,

(AH)

4 = Clinical Officer, 5= Ohers

HIVPositve(R) HIVNegatve(R)