The Chiawelo Community Practice reports monthly using the tool: Chiawelo Monthly Report Form.
The Household Registration form (as well as Individual/Maternal forms) gets placed in a CHW file per family once captured on the CHW Family Profiles. A blank page is added for notes. The CHWs file has a cover page (Chiawelo CP Folder Family) and a genogram inside (Chiawelo CP Folder Genogram).
The CHWs file is kept together with the Community Practice records: a Family Folder ((Chiawelo CP Folder Family) a Patient Folder for all members of the member (Chiawelo CP Folder Patient) and a Problem List on the inside cover of each Patient Folder (Chiawelo CP Folder Problem List). All Household Registration respondents and patients visiting the Community Practice sign a Consent Form (Gauteng FM Consent Form). All clinicians are given the International Classification of Primary Care 2-pager (ICPC Code Sheet) and asked to collect data using this tool (ICPC 2 Data_Collection_Sheet) in addition to collecting DHIS data. Each clinician is given a box of 'goodies' and an orientation (Instructions for clinicians) to the clinical workings of CCP.
We are also working hard to improve Ongoing Care. We have a a record kept by clinicians CCP Ongoing Care Record CLINICIAN 14-10-16, supplemented by a record of functionality CCP Review of functioning and ability. We also work with CHWs to follow up and provide them a plan/record for follow up CCP Ongoing Care Record CHW 14-10-16. This is kept in the CHW folder. As we manage the patient month-by-month we decide that if the patient is stable and not needing monthly visits to us that we can plan it accordingly using the Ongoing Care Records. We ensure the patient gets their medication safely and securely and is followed up regularly by CHWs with a CHW Delivery System using a CCP Chronic Script and a CCP Chronic Delivery form. The CHW record and copies of delivery are kept in the patients folder enabling clinicians to see them for any acute condition and check on their ongoing care. Patients are overjoyed!