Chapter 9. Recording, reporting and data use Final.pptx

11/02/2025 Malaria Case Management for Health Care Workers 1
Malaria case management
training for Health professionals
Chapter 9:
Recording, Reporting and Data Use
March 2024
Addis Ababa

Chapter Introduction
Chapter title: Recording, Reporting and Data Use
Duration: 180 minute
Chapter Learning objectives
At the end of this training, participants will be able to:
 Demonstrate understanding proper use of malaria cases
management data
 Recognize key malaria program indicators
 Properly Report and transcribe all malaria cases according to the
national classification of disease
 Properly Record all malaria cases using OPD/IPD registration
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Malaria Case Management for Health Care Workers

Chapter introduction cont’d
Chapter outline/Sessions
Session 9.1 Malaria program data and indicators
Session 9.2 Malaria cases recording and reporting

Session 9.1 Malaria program data and indicators
Session Objective:
At the end of this training, participants will be able to:
 Demonstrate proper use of malaria cases management data and
 Recognize key malaria program indicators
Duration: 80 minutes

Introductory activity: Self reflection
Before moving to the session, go over the following
questions to retrieve your previous knowledge and
experience. Feel free to answer/reflect on the question.
Q. From your experience what are the types of data sources for
malaria case management activities?
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11/02/2025 Malaria Case Management for Health care workers 6
Importance of data
 Primarily data should be used to inform decision-making
 A few examples of how data collected from a program, or an intervention
can be used::
o To help to inform policies, planning or program decisions.
o To raise additional resources for scale-up of programs or for future
programs.
o To assess whether a program has produced the desired or intended
impacts.
o To strengthen programs by improving their quality of services provided
by the program
o To ensure accountability and for reporting purposes.

Health information system
HIS It refers to a system that captures, stores, manages or transmits
information of:
The health of Individuals
Activities of Organization
 Information is crucial to inform on the performance of the health system
and about health challenges
Heath Information system is required for timely intelligence on the other
building blocks of the health system:

Data source
1. Institution based sources; its components are
 Individual records
 service records, supplies
 administrative reports Routine HMIS,
 inspection, surveillance Facility-based surveys: SARA, SPA+,
2. Population-based sources; its components are
 Census
 civil registration
 population surveys/DHS
 Malaria indicator survey/MIS,
 Multiple Indicators Cluster survey/MICS, etc) and other program specific surveys and researches

Malaria program indicators
Activity 2
•What is HMIS?
•What is the Purposes of HMIS?

Indicators…
HMIS
is the routine collection, aggregation, analysis, presentation and utilization
of health and health related data for evidence-based decisions for health
workers, managers, policy makers and others.
Purposes of HMIS
Availing accurate, timely and complete data to support decision making
at each level of the health system
Strengthening the use of locally generated data for evidence-based
decision making
Components of HMIS
1. Information management
2. Using information for management purposes

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Group activity
Group Activity
Practice activity
Objective : To understand data element and indicators
Instruction ; Be in group of 4-6
Read, analyze and identify the given data element and indicators
Instruction: Be in group of 4-6
Read and analyze the data provided and write down data elements and
indicators in your notebook.
Time; 30 minutes

Practice exercise ….
o Morbidity attributed to malaria
o HMIS disease classification
(disaggregated by age, sex and
visit type)
o New visit
o Facility based death attributed to
malaria
o Proportion of confirmed malaria
cases fully investigated and
classified
o Proportion of foci fully investigated
and classified
o Malaria cases with travel history
o Number of index cases investigated
and classified
o Number of secondary cases
o Malaria positivity rate
o Repeat visit
o Annual parasite incidence

National malaria indicators
Sr # Indicators Monthly
HP HC Clinic HOSP
1 Morbidity attributed to malaria X X X X
2 Facility based death attributed to malaria X X X X
3 Malaria positivity rate X X X X
4 Proportion of confirmed malaria cases fully investigated and classified X X X X
5 Proportion of foci fully investigated and classified X X X X
6 Annual parasite incidence X X X X
7 Proportion of unit structures covered by Indoor residual spraying
8 Proportion of health facilities covered by External Quality Assurance (EQA) for malaria
diagnosis

Reportable data element
1. Malaria cases with travel history
2. Number of index cases investigated and classified
3. Number of secondary cases
4. Number of foci investigated and classified

Session summary
Indicator: Measures, usually core set of indicators (determinants,
inputs, outputs, outcomes & health status)
The sources for the HMIS indicators are primarily data collected from
routine health and administrative services. The indicators from the
routine HMIS can further be triangulated with other sources such as
household surveys, facility surveys, surveillances, research studies and
others.

Reference
1. ESV-ICD 11 implementation Guide
2. ESV-ICD 11 SOP

Session 9.2.
Malaria cases recording and reporting

Session 9.2.
Malaria cases recording and reporting
Session Objective:
At end of this training, participants will be able to:
• Properly Record all malaria cases using OPD, IPD, Emergency, Malaria
health center registration
• Properly Report and transcribe all malaria cases according to the
national classification of disease
Duration: 100 minutes

Introductory activity
What Is The Importance Of Medical Records In Healthcare?

HMIS Recording, Reporting tools and procedures
 The recording instruments are developed based on the level &
capacity of the health institutions and the scope of health
services they deliver
Health centers and hospitals (including private for profit and
private for not profit facilities) use individual medical records and
registers
In order to simplify report compilation, tally sheets are
developed for each level

HMIS Recording Cont’d
Patient form/patient card
•Patient card is a free form and has three
sections:
• Section to write chief complaint and detailed
clinical notes
• Section to write the main diagnosis and other
diagnosis (if any).
• Section to write NCoD (National Classification of
Disease)

OPD/IPD registration
• New Visit is patient visit for a new episode of illness.
• Repeat Visits a patient who visits the health facility for the same
episode of illness and or for follow up etc.
• Note: The ultimate decision, whether a client/patient is defined
as new, or repeat diagnose is left to the knowledge of attending
clinician

Importance of medical records
1. Reduces Risk Of Malpractice
2. Helps To Maintain Communication amongst Healthcare Personnel
3. Ensure You Get Reimbursed
4. It measures Health service quality

Transcribing and Reporting
Ethiopia simplified version of international classification of disease
(ESV ICD-11)
• International Classification of Diseases is a tool for recording, reporting
and grouping conditions and factors that influence health
• Its purpose is to allow the systematic recording, analysis, interpretation
and comparison of mortality and morbidity data collected
• Classification is mainly based on anatomical sites & has single hierarchy
• Has rules and conventions to record and report causes of morbidity and
mortality

Transcribing and Reporting cont’d
(ESV ICD-11)
• The main condition is defined as the condition, diagnosed at the
end of the episode of health care, primarily responsible for the
patient’s need for treatment or investigation.
• If there is more than one such condition, the one held most
responsible for the greatest use of resources should be selected.

(ESV ICD-11)
‘Not elsewhere classified’ : Serves as a warning that certain specified
variants of the clinical concept may appear in other parts of classification
• ‘……Unspecified’ implying the source documentation used for classifying
did not provide more detail beyond the term. Unable to further classify the
disease.
E.g. Syphilis, Unspecified.
• ‘Other specified….’ implying the source document /clinician able to
specify the diagnosis but not included in the list.
• If no diagnosis was made, the main symptom, abnormal finding or
problem should be selected as the main condition.

(ESV ICD-11)
‘Underlying cause of death: is the disease which has initiated the series
of illnesses leading directly to death, or the circumstances connected
with an accident or an act of violence which caused the injury or
poisoning leading to death.
The concept of the ‘Underlying Cause of Death’ (UCOD) is central to
mortality recording and reporting.

(ESV ICD-11)
• Immediate cause of death: It refers to the disease, failure
of injury whose symptoms cause the person to die.
• Intermediate cause of death: refers to the condition which
leads from the underlying cause of death to the immediate
cause of death.

Malpractices of disease recording & reporting
• Recording ‘abbreviation’
• Unmarking the main diagnosis
• Unable to identify the main diagnosis as new or repeat
• Writing the clinician’s textbook diagnosis on the register (no
transcription)
• No communication and feedback among participating actors
(Clinicians, HIT and Nurse Assistants)

Group activity
Activity
Instruction: Read general rules from participant manual page 190
and explain what you understand to plenary.
Time: 20 minutes

Procedure of mortality recording and reporting
Recording
 Done by a clinician on the patient card/form
 Free/open diagnosis
Cause of death: In the event of a death, the health care provider who
attends the death is expected to document/ record cause of death in
three levels based on the definition in the ESV-ICD 11 implementation
guide: Immediate/direct; Intermediate and Underlying
Patients who died at arrival before admission/at emergency should
not be counted as deaths from OPD, emergency, IPD, ICU and NICU

Transcription to registers
 Once all basic recordings are made by clinicians and only by clinicians on
the patient form/card, the next step is to transcribe into the registers
depending on the units the patient is diagnosed and treated.
 Transcription should by word for word/verbatim
• The transcription is done by the below cadres depending on circumstances.
• Nurse assistant: Tertiary and general hospitals ,as well as and also
primary hospitals and health centers, depending on availability.
• Clinicians: Mostly at primary hospitals and health centers in situations
where nurse assistants are not available.
 Summering the data into tally sheet

Entry into DHIS2/eCHIS
• Only ‘underlying cause of death entered DHIS2/eCHIS
• In general, this is expected to be done by HITs unless
absence/shortage prompts other options.
• Entry into eCHIS can be done by comprehensive health posts upon
implementation the Health extension roadmap and design of ESV-ICD
11 in eCHIS in the future

Malaria Program data collection system
Data flow
Facility Based
Data
Service delivery/disease report
WorHO/
ZHD
Compiled and
used /
reported
RHB
Compiled
and used /
reported
Compiled
and
used
Community
Based
Data

Cont’d
• Malaria data information is based on data collected through
regular reporting systems (PHEM and HMIS) and surveys
and evaluations conducted periodically which includes MIS,
malaria program review and drug efficacy studies.

Activity
Instruction
• Be in pair and
1. Fill the OPD abstract register accordingly.
2. What NCoD do you write on this register?
3. List appropriate tally/ies she can be considered.
Use participant manual case scenario activity 3 197
Time 20 minutes

Session Summary
• Main diagnosis may or may not exactly fit NCoD; however, it should be
made to match into the NCoD for national reporting.
• If there is more than one such condition, the one held most
responsible for the greatest use of resources should be selected.
• The mode of death such as cardiac arrest or respiratory failure
should not be reported as immediate cause of death.
• Deaths on arrival should not be transcribed to registers
• Restrict follow the above rules.

References
1. ESV-ICD 11 SOP
2. Ethiopian Health Management Information
System: Data Recording and Reporting
Procedures Manual

.
Thank you

Chapter 9. Recording, reporting and data use Final.pptx

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