The Ethiopian Public Health Institute Ministry of Health-Ethiopia
Chapter 7
Documents & Record Keeping
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Content Outline
• Essential elements of Record Keeping
• Laboratory request and report forms
• Entry of data into the Laboratory Register
• Reporting of Malaria Data
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Learning Objectives
At the end of this chapter, the participant will be able to:
• Describe essential elements of recording and reporting
• Report microscopy results on the laboratory request form
• Record microscopy results correctly in the Laboratory Register
• Describe how to Report Malaria Data
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Essential Elements of Record keeping
Activity 7.1. Self-reflection
Instruction: Read the following question and
answer it.
Question: What is the difference between
document and records?
Time:3 minutes
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Essential Elements of Record keeping…cont’d
• Recording means keeping the register up-to-date.
• Proper recording and reporting of patient data used to
• Determine work load
• Planning of resources
• Compile important epidemiological information for malaria prevention and
control program.
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Record keeping
Accurate record keeping is based around four elements:
• Completeness
• Consistency
• Credibility
• Timeliness
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Record keeping
Therefore, Laboratory supervisors should regularly review
• Specimen Request forms
• Laboratory Register
• Result Reports
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Laboratory Request and Report Forms
Activity 7.2. Think/Pair/share
Instruction: first think about the following question and
then discus in pair with a participant sitting next to you
and share your idea
.
Question: List the contents in which the reports should
include?
Time: 3 minutes
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Laboratory Request and Report Forms…cont’d
A completed Laboratory Request Form should give the following information:
• Name of health facility
• Date
• Patient’s name, address, age, and sex
• Type of specimen
• Patient ID/ Specimen ID number (laboratory serial number)
• Clinical impression
• Signature of person requesting exam
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Microscopy Report
The microscopy report should include the following information:
Specimen ID number
Date & time of Specimen collection
Date of specimen analysis
Blood film result (presence of parasite, species, stage and parasite count/density
against WBC)
If necessary (high parasitemia) percentage of infected RBC in Thin films
Name and Signature of Laboratory technician performed the test
Name and Signature of Laboratory technician Reviewed the result
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Example of Results Reporting (Annex C – 6)
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Consequences of Incorrect Reporting
• False Negatives: Patients with malaria who receive a false negative
result may not be treated, resulting in ongoing disease, disease
transmission and possibly death.
• False Positives: Patients who receive a false positive result for
malaria will be treated unnecessarily, given the wrong medications
(malaria medications) and in turn medications will be wasted.
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The Laboratory Register
Activity 7.3. Think/Pair/share
Instruction: first think about the following question and then
discus in pair with a participant sitting next to you and share
your idea.
Question: List the data which are entered into the laboratory
register
Time: 3minutes
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The Laboratory Register…cont’d
• Is a record book maintained by the laboratory personnel
responsible for blood film examination.
The laboratory register should include:
• Laboratory serial number
• Date of collection & specimen testing
• Patient’s name, sex, age, and address
• Type of test
• Test results
• Signature of person responsible for tests/Reviewing
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Malaria Data Report
Activity 7.4. Self-reflection
Instruction: Read the following question and answer it.
Question: What is the function of recording malaria data
Time: 3 minutes
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Malaria Data Report…cont’d
• Compiled from the laboratory log book on weekly, monthly, quarterly
and yearly basis.
• This will give us evidence on the workload of health facility laboratory
for further planning of resources.
• Have significant input to show the prevalence of laboratory
confirmed malaria cases in the facility.
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Malaria Laboratory Performance report form
Blood film Negative Positive P. falciparum P. vivax Mixed P. Ovale P. Malerea
performed ( P. f and P.
v)
Total
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Laboratory Confirmed Malaria Case Report Form
• Done by reviewing the malaria register and counting the number
of blood films reported as positive with their species name and
negative slides.
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Summary
•Accurate record keeping is based around four elements:
completeness, consistency, credibility and timeliness.
•Laboratory report should comprises all required information
•All the data should be recorded properly on the log book with
fulfilling the four essential elements.
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