Record keeping and filing

Clinical description

Confidentiality of patient records

• All patient cards and clinic registers are property of the MOH and may only be kept at the

respective facility or at the National Archives.

• Patient cards and clinic registers must be kept in a locked room and are only to be accessed by

clinic staff responsible of providing the respective service and by the national supervision team.

Patients and named guardians have access to their own patient card.

Use of clinic registers (ANC, Maternity, HCC, ART)

• Keep patient registration for each different service centralized in each facility: Use only one set of

registers in each facility.

• Each patient has only one row 4 in each register: Continue using the same row for returning

transfers and re-starts after default or stop.

4 In the ANC register, each woman has one separate section with rows for each subsequent visit.

Monitoring and evaluation

• Turn to a new page when starting to register patients in a new quarter. Leave any unused rows at

the bottom of the previous page empty. This is to separate the quarters when adding page totals.

• Assign continuous registration numbers (by sequence of registration). Take care not to duplicate

registration numbers.

o Continue assigning cumulative registration numbers in the HCC- and ART-Register. These number series are never re-started.

o Re-start assigning registration numbers annually for the ANC- and Maternity Register. Re- start with number 1 on the 1st of July.

Use of patient cards

• Each patient has only one patient card at any one time (Exposed child, ART). Attach another patient

card once the old card is full.

• Patient cards are filed in polythene sleeves in lever arch files, up to 100 cards per arch file.
• Separate filing systems are used for the different types of patient cards:

Exposed Child under 24 Months cards

• File in batches by year and month of birth.
• Within each birth month, sort in ascending order by HCC registration number.
• Do not remove the cards of children who have started ART, died, defaulted or transferred out from

this filing system.

• Files with birth cohorts who (would) have now reached at least age 3 years can be removed from

the clinic for archiving.

ART Patient cards, paediatric and adult ARV formulations

• File ART Patient Cards in ascending order by ART registration number.
• Prepare separate filing systems for ACTIVE (retained in ART) and INACTIVE patients (stopped ART,

transferred out, defaulted, died).

• One arch file can hold approximately 100 cards.

o Label the ACTIVE files with ART numbers 1-100, 101-200, 201-200, etc.

o Label the INACTIVE files with ART numbers 1-200, 201-400, 401-600, etc.

• Each time the quarterly cohort analysis is done, update in the ART register the outcome for patients

who have dropped out of ART (stopped ART, transferred out, defaulted or died). Straight after this, move these cards of from the ACTIVE to the INACTIVE filing system.

• Do not separate paediatric and adult ARV formulation cards into different files.