Clinical Mentorship chart and record abstraction tool
Name of Mentored Facility: ________________________ Name of Mentor:
_______________________ Date of Visit: ________________
First 95 (HTS-TST) Number /proportion Remark
Service Delivery points (OPD/IPD)
Total tested
Total positives
Total linkage (Newly identified positive registered in
positive tracking tool)
Assess the utilization of HIV Risk Screening Tool
(HRST) at selected service delivery points (SDP)
including under five and PMTCT
# Patients Visited HFs
# Patients Screened
# Eligible for HIV testing
# tested for HIV
# Positive
# Linked to ART
Assess the implementation of HIVST (both directly
assisted & unassisted HIV self-test)
Proportion of individuals for whom Recnecy
testing is done out of newly identified in the month
Proportion of individuals for whom Recnecy test is
done and HIV case base surveillance format is
completed
TB clinic Number /proportion Remark
Proportion of TB patients tested for HIV
Proportion of HIV positive TB patients with contacts
tested for HIV
Coach on HIVST use to reach contacts of HIV
positive TB patients, who may want to self-test?
Proportion of newly identified HIV positive clients
linked to ART
Proportion of HIV positive TB patients on ART
Proportion of HIV positive TB patients on CPT
Key population (KP) friendly services (only for Number /proportion Remark
KP sites)
KP performance cascade in the last month
# of FSWs tested in the last month
# of FSWs tested positive in the last month
# of FSWs linked to ART
Proportion of HIV positive FSW on ART
# of eligible clients counseled and enrolled on Pre-
Exposure Prophylaxis
Social Network Strategy (SNS) testing performance
the last month (Only for KP sites)
# Of Total tested for HIV( Seeds & members) tested
# Of Total HIV positives identified
# Of linked to care
ART clinic
ART clinic: Draw 3 adult, 3pediatrics ART chart and 3 high viral load clients chart
Performance
First 95 -ICT Adult Pediatrics Remark
Number of charts with attached and updated family
matrix /reminder
Check and coach to provide ICT to all index cases
Check the availability of counseling script and coach
on its use to help contact elicitation
Proportion of family members of index cases tested
Number of high VL charts with attached and updated
family matrix /reminder
Proportion of high viral load (HLV) index case
contact tested for HIV
Assess Partner & Family based ICT cascade in the
last month
Index Offered
Index accepted
Contacts tested
Tested Positive
Check and coach on HIV self-test use as an option to
reach the contacts of index cases, who are not
coming to facility for testing?
Check and Coach on use of Virtual Phone counseling
to counsel clients in the context of COVID-19
and to reach clients on MMD?
If Yes, verify and encourage to enhance follow up
phone counseling
If No, discuss and guide to use virtual phone
counseling
nd
2 95 at ART clinic Adult Pediatrics Remark
Growth monitoring for children<15yrs of age
Prevention counseling (Family planning, STI and
condom use)
Check disclosure and establishment of psychosocial
support services
CD4 determination done as per the guideline
(Baseline & as indicated)
CPT provision for eligible clients
TPT (TB preventive Therapy)
Clients initiated ART as per the guideline (within a
week including same day, if not specify the reason on
the remark)
% of newly started ART clients enrolled in 3MMD
% of total clients enrolled in MMD(Multi month
dispensing)
Viral load determination done as per the guideline
Check for treatment failure evidences
(Clinical/CD4/VL pattern) & its management
Review completeness and consistency of the
Enhanced Adherence Support ( EAS ) on the high
viral load register for at least five clients records
# of client lost to follow up in the last quarter
# of lost to follow up clients retuned back and
restarted ART
Ensure integration of gender based violence, family
planning, mental health and cervical cancer screening
and treatment service
# of PLHIV women who are eligible for cervical
cancer screening
# of PLHIV women who are counseled and linked to
cervical screening unit
# of PLHIV women who are screened for cervical ca
# of PLHIV women who are screened positive
Proportion of PLHIV women with positive screening
and treated/referred
Check HFs are identifying clients who are adherence
at risk and timely enroll to care plan (check adherence
at risk registration book and care plan provision status
of case managers)
Review monthly retention data,identify gaps, provide
technical support and take remedial action
Review last two months record on positive tracking,
ART and HVL register and assess for Completeness
and updates
3rd 95 at ART clinic Number % Remark
Number of viral load sample sent in the lastmonth
Number of viral load result returned
Percentage of VL result returned within standard
TAT (25 days)
Number of high viral load result
Proportion of high VL clients tracked and enrolled to
EAS within a week
% of clients with high viral load completed EAS
sessions
% re-suppression among clients second VL test result
returned
Number of clients switched to second /third line ART
regimen
PMTCT clinic: Draw 3 PMTCT ART charts, 3 HEIs and 3 high viral load clients chart
First 95 at PMTCT clinic PMTCT HEI client Remark
client
Number of charts with attached and updated family
matrix /reminder
Proportion of family members of index cases tested
for HIV
Number of high VL charts with attached and updated
family matrix /reminder
Proportion of high viral load (HLV) index case
contact tested for HIV
Assess the presence of linkage missed opportunity at
ANC, L&D, PNC and FP clinic and document
reasons in the remark column
Assess the level of testing missed opportunity of
partner of HIV positive and high risk negative clients
at ANC, L&D, PNC and FP clinic clients and
document reasons in the remark column
Proportion of DBS test done within 2months of age
in the last quarter
Proportion of DBS test done 2-12months of age in
the last quarter
PMTCT HEI Remark
2nd 95 at PMTCT clinic clients clients
Prevention counseling (Family planning, STI and
condom use)
CD4 determination done as per the guideline
(Baseline & as indicated)
CPT provision for eligible clients
TB screening
TPT (TB preventive Therapy)
Clients initiated ART as per the guideline (within a
week including same day, if not specify the reason on
the remark)
% of total mothers enrolled in 3MMD(Multi month
dispensing
Viral load determination done for PMTCT clients
aspertheguideline (Newly diagnosed: at 3 months of
ART initiation followed by every six months
Until the MTC risk ends.)
Check for treatment failure evidences
(Clinical/CD4/VL pattern) & its management
Review completeness and consistency of the
Enhanced Adherence Support( EAS ) on the high
viral load register for at least five clients records
# of clients lost to follow up in the last quarter
# of lost to follow up clients retuned back and
restarted care
Review last three months record on PMTCT cohort
register and assess for Completeness and updates
Check growth monitoring status for HEIs
(Is the growth curve attached, plotted and appropriate
action taken)
Check provision of dual ARV prophylaxis for the
newborn
Check CPT provision for HEIs
# of PLHIV mother who are eligible for cervical
cancer screening
# of PLHIV mother who are counseled and linked to
cervical screening unit
# of PLHIV mother who are screened for cervical ca
# of PLHIV mother who are screened positive
Proportion of PLHIV women with positive screening
and treated/referred
3rd 95 at PMTCT clinic Number percentage Remark
Number of viral load sample sent in the last quarter
Number of viral load result returned
Percentage of VL result returned within standard
TAT (25 days)
Number of high viral load result
Proportion of high VL clients tracked and enrolled to
EAS within a week
% of clients with high viral load completed EAS
sessions
% re-suppression among clients second VL test result
returned
Number of clients switched to second line/third ARV
Regimen
Supply management Yes No Remark
Is HIV test kit audit practiced?
Is there rapid HIV Test Kits shortage and stock out
currently?
Check for stock out of ARV drugs and document
reasons on remark column if there is stock out
Check for stock out of OI drugs (TPT, CPT,
Pyridoxine…) and document reasons on remark
column if there is stock out)
Is there DBS Kits/VL supplies stock out currently?
Is patient Information Sheet utilized to identify and
correct medication errors?
Facility ownership Yes No Remark
Is implementation of CM feedback related activities
carried out?
Is regular MDT/PMT Meeting conducted (if not
specify the reason)
Is quality improvement project design for major
service gaps
Is internal/external mentorship done as per the plan
