Missed Appointment Tracking Register
Demographics
Medical No:
Family Name:
Given Name:
Middle Name:
Name:
Gender:
...
Male
Female
Date of birth:
Appointment Information
Missed Appointment Date:
*
Service Point
*
...
ART Clinic
TB Clinic
Other
Other Service Point
*
Medication Due for Refill
*
ART
TB Meds/TPT
Infant NVP/CTX
FP
Other
Other Specify:
*
Mode of Care
*
...
1 - FBIM
2 - FBG
3 - FTDR
4 - CDDP
5 - CCLAD
Tracking Information
Follow Up Attempt
*
...
1 - Follow Up 1
2 - Follow Up 2
3 - Follow Up 3
4 - Follow Up 4
5 - Follow Up 5
6 - Follow Up 6
Followup Date
*
Follow Up Person:
*
Followup Action
*
Phone call to client/caregiver/next of Kin
Home/workplace visit by HCW
Facility to facility phone call
Facility to facility visit
Other
Other Follow up actions
*
Follow Up Outcome
*
1 - Returned to care
2 - Self transferred
3 - Stopped/Refused
4 - Migrated/Relocated
5 - Died
6 - Unable to be traced
7 - Tracing attempts initiated but incomplete
8 - No attempt to trace
9 - Misclassified as Missed Appointment
ART Clinic
*
ART Number
Followup outcome by end of current quarter
1 - Returned to care
2 - Self transferred
3 - Stopped/Refused
4 - Migrated/Relocated
5 - Died
6 - Unable to be traced
7 - Tracing attempts initiated but incomplete
8 - No attempt to trace
9 - Misclassified as Missed Appointment
Followup outcome by end of next quarter
1 - Returned to care
2 - Self transferred
3 - Stopped/Refused
4 - Migrated/Relocated
5 - Died
6 - Unable to be traced
7 - Tracing attempts initiated but incomplete
8 - No attempt to trace
9 - Misclassified as Missed Appointment
Date Returned to Care
Date Self Transferred
CAUSE OF DEATH
1 - TB
2 - Cancer
3 - Infectious disease other than TB
4 - HIV Non-infectious disease
5 - Natural causes
6 - Non natural causes
7 - Unknown
Clinical impression comment
Follow Up Person's System ID:
*
Encounter Location:
*