STI daily Log

Facility name: Department:

STI LogBook: Instructions for LogBook Completion
Register Serial No.: Ongoing numbering (001, 002, 003, etc)
Date of Visit: Day / Month / Year
NID/NUIC: Clinic UIC for patient
Age: In Years (for children, write as a fraction, ie 1/52 for one week, 3/12 for 3 months)
Sex: M=Male F=Female TG=Trangender
Target Pop: write code for target population from decision tree FSW, MSW, MSM, TG, HR, GP
Referral From: write in where the patient was referred FROM (PE, HIV, ANC, Outpatient,TB, Outreach, Other).
Reasons For Visit: New Case, Review Case, Partner, Re-Infection
HIV Status : HIV Status Pos=Positive, Neg=Negative, Unk=Unknown (if last HIV test >3months ago)
Patient HIV Status: HIV status of Regular patient
Pos=Partner is known po
Neg=Partner is known negative (tested in past 3months)
Unknown=does not know partner status OR partner tested greater than 3months ago
None=client does not have regular partner at this time
PICT today: IF PICT done today BY STI nurse – Pos=Positive result, Neg=Negative result, ND=not done
GBV Screen: Pos=GBV Neg=No GBV Declined=GBV ND= Screening Not Done
Presumptive Treatment Given: Y=Yes N=No
Syndromes: Write code for Syndrome: Urethral Discharge Syndrome, Vaginal Discharge Syndrome, Genital Ulcer Syndrome, Lower abdominal Pain Syndrome,Scrotal Swelling, Anorectal - related Syndrome, Neonatal Conjunctivitis, Other STI's
Laboratory: (Tick as applicable)
G.Stain Wet Mount Culture PCR TPHA VDRL RDT
Etiological Dx: Write code Etiology? (Gonorrhoea, Chlamydia, Trichomoniasis, Hepatitis B, Herpes, Active Syphilis, Latent Syphilis, Donovanosis.)
Treated: Y=Yes N=No
If NOT treated, Reason? Declined, Stock-out, Referred
Partner Management: tick if referral card given and if partner treatment given.
Other Referrals Made: tick in the box of the referrals made today
Initials: Initials of STI Nurse/Health care worker
Planned Date of Review: Scheduled Review Date
Review Visit
Date of review: write in date (day/month/year) only if client returns for review
Symptoms: Y=Yes, Symptoms N=No, no symptoms
Partner treated: Y=Yes N=No N/A=not applicable for this client (no partner, not infectious disease, etc
Assessment: Res=Resolved U/P=Unresolved or Persistent Re-Inf=Reinfected Comp=Complication
Referrals made: if any referrals made at the review visit.
Register Date of Target Pop Referral Reason for HIV Status & GBV Presumptive Syndromes Partner Initials Planned
Serial No. Visit Patient Information FSW, MSW , From? Visit? Screen Treatment Write code for Laboratory (Tick as applicable) Other Referrals Made Date of Review Visit
Testing Management
MSM , TG, PE, HIV, New Case, Pos, Given Syndrome: If NOT Review
HR, GP ANC, TB, Review Case, Neg, Y / N UDS, VDS, treated,
Outpatient, Partner or Patient Declined GUS,LAPS, Etiological Treated Reason? Partner

Wet Mount
Re-infection Status PICT Referral Partner Assessment

Specialist
Outreach, , ND ARS,SS, NC Dx: GC, Date of Sympto Treated

G.Stain

Culture
Y / N Declined, card

TPHA
VDRL

Other
Sex Today Trt. Res, U/P, Referrals

GBV
PCR

RDT

HCT

ART
Others

TB
FP
NID/NUIC Age/Unk Pos, CT, Trich, Stock-out, tick if Review ms ?
M,F,TG Pos, tick if Re-Inf, Comp Made
Neg, HepB, HSV, Referred actual visit Y, N Y, N,
Neg, ND given given
Unk Syph, DNV N/A