NTP Quarterly Report on Hospital TB Referrals

For the ______ Quarter, Year__________ Name of Hospital Location Prepared by Reviewed by
Name & Signature

Category TDPH Date submitted ___________________________ Designation ___________________________ Designation

Name & Signature

TDRH

1 2 3 4 5 6 7 8 9 10 11 12 13

Indicators Total no. of referrals (TB symptomatics/ suspects / patients) to hospital TB team From the wards From OPD Others No. of TB patients admitted at the ward (discharge census) Intrahospital referral rate (ward) [No. 2/No.5 x 100] No. of smear positive detected by laboratory Laboratory referral rate (No. 10/No.7 x 100) Internal referrals that were confirmed as TB cases (by TB clinic) New smear positive TB cases TB cases referred to peripheral DOTS facilities (external referral) TB cases registered by TDPH (managed by the TB clinic) No. of TB cases started treatment at the ward

No.

Referral outcome of patients referred during the quarter prior to this reporting period: Total no. of TB cases referred to peripheral DOTS facilities during the 14 quarter prior to this reporting period 15 16 No. accepted and registered (with TB case number) at the peripheral DOTS facility External referral acceptance rate (No. 15/No. 14 x 100)
%