PROGRAM-BASED SERVICE DELIVERY MONITORING TOOL (for DMO) version 4

Province of :_______________________________
Name of Municipality:_BAYAMBANG RHU II Inclusive dated of Reporting: APRIL 2018
FAMILY HEALTH
MATERNAL CARE FAMILY PLANNING
Live births
Eligible Population (2.7%)
Deliveries Eligible Population(12.325%)
Deliveries in a health facility (FBD) No. of Current Users (end in all methods)
Deliveries attended by skilled health professional (SBA) Contraceptive Prevalence Rate
Pregnant women with 4 or more prenatal visit (4ANC) No. of women with Unmet Need tracked (NHTS)
Postpartum women at least (2PPV) No. of women with Unmet Need tracked (non-NHTS)
Maternal Mortality Ratio % Unmet Needs
Neonatal Mortality Rate Total no. of WRA (15-49 yrs. Old) actually reached
Infant Mortality Rate identified with unmet need
Under-five Mortality Rate New acceptors of modern FP methods through
Stillbirth Rate post partum FP
Adoscent Pregnancy Rate New acceptors of modern FP methods through
Teenage Pregnancy Rate outreach missions
New acceptors of modern FP methods provided in
NATIONAL IMMUNIZATION PROGRAM regular public health facilities
No. of Fully Immunized Children Total no. of new acceptor fpr modern FP
% Fully Immunized Childred No. of served (provided with FP commodities)
No. of Completely Immunized Children ORAL HEALTH
% Completely Immunized Children Eligible Population (13.5%)
NEWBORN SCREENING PROGRAM No. of Orally Fit Children upon examination
No. of Newborn Screened No. of Orally Fit Children upon complete oral
% Newborn Screened rehabilitation
No. of Dissents (refusal) No. of Children (6-71 mos old) with dental carries
% of Dissents (refusal) % Orally Fit Children
No. Confirmed Positive BASIC ORAL HEALTH CARE
% of Confirmed Positive 6-71 months old with BOHC
No. Positively Screened 6-9 years old with BOHC
NUTRITION 10-24 years old with BOHC
% Underweight Children 24-59 years old with BOHC
% Stunted Children 60 years old & above with BOHC
% Wasted Children Pregnant women with BOHC
NON-COMMUNICABLE DISEASE
MORBIDITY MORTALITY
(cases) (deaths)
Cardiovascular Disease Thyroid Disorder
a. Heart Disease a. Clients diagnosed/referred/managed
b. Vascular Disease Risk Factors
c. Clilents diagnosed & managed a. No. of clients 25y/o and above overweight/obese
Diabetes Mellitus b. No. of currents smokers (all ages)
c. No. of high risk adults (>30% CVD risk)
a. Clients diagnosed & managed
d. No. of clients with mass (all forms)
Cancer e.No. of clients 25 years old and above screened
a. Breast and assessed using PhilPEN
b. Prostate Mental Health
c. Lung a. No. of mental health patients
d. Cervical b. Is your RHU catering mental health services?
* Note: If Yes= 1, No=0
e. Colorectal PWDs
f. Thyroid a. No. of PWDs provided with at least 2
g. Liver health services
h. Others b.PWDs referred for possible provision

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 h. Others
i. Clients diagnosed & managed
COPD
a. Clients diagnosed & managed
Kidney Disease
a. Clients diagnosed & managed
b. No. of patients undergoing
dialysis
of assistive device
c. PWDs provided with assistive device
Senior Citizen
a. SC Provided with at least 2 health services
Injuries and Accidents
a. No. of deaths due to vehicular accidents
b. Other accidents and injuries

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 No. of served
NO. (provided with FP
commodities)

MORBIDITY MORTALITY
(cases) (deaths)

Number

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Page 4
 INFECTIOUS DISEASE LOCAL HEALTH SY
A. Dengue A. HEALTH BUDET
No. of suspected cases tested with dengue NS1 Total Health Budget Allocated
No. of positive cases with NS1 % of health budget expenditures
Dengue Morbidity Rate B. HEALTH FACILITY
No. of dengue deaths No. of health facilities
Dengue Mortality Rate No. of health facilities with functional EMR
B. Malaria No. of MD to population ratio of 1:20,000
No. of confirmed malaria cases No. of PHN to population ratio of 1:20,000
No. of blood smears collected and examined No. of RHM to population ratio of 1:20,000
Malaria Morbidity Rate No. of brgys w/ at least 1 dedicated public health worker
C. Rabies No. of MD
No. of rabies cases No of RN
Rabies Incidence Rate No. of RM
D. Schistosomiasis C.BHW
Schistomiasis Prevalence Rate No. of BHW's enrolled to philhealth
E. STH deworming No. of functional LHB-BHW RAC
No. of population dewormed (5-65 y/o) No. of registered and accredited BHW's (rendered 3yrs an
voluntary health services)
No. of population dewormed (1-18 y/o) Approved and signed BHW masterlist
Soil Transmitted Helminthiasis Prevalence Rate Allocation of funds for BHW Incentive to registered and a
F. Leprosy D. GIDA / IP HEALTH
No. of Leprosy cases No. of deployed health human resource at GIDA/ICCs - IP
Leprosy Prevalence Rate No. of GIDA/ ICCs- Ips visited
G. Tubercolosis No. of GIDA/ICCSs -IPs rendered health services
No. of TB cases (new + relapse) Inclusion/allocation of funds for IP health programs and a
LIPH of integration of IP health programs/activities in the
No. of presumptive TB cases referred for GENE-XPERT E. SERVICE DELIVERY NETWORK (SDN)
TB indidence Rate No. of barangays/municipalities
EPIDEMIOLOGY & SURVEILLANCE UNIT No. of BHS and exact location
Foodborne/waterborne illness Status of Philhealth Accreditation of the health facility
Chemical Poisoning No. of referral facility, their name and exact location
MERSCoV Person under investigation Name of apex location
EBOLA Person under Investigation NATIONAL VOLUNTARY BLOOD S
Maternal Death (direct cause) No. of blood donors
Notifiable diseases/syndrome under Category 1 (Immediately Notifiable) No. of repeat donors
Acute Flaccid Paralysis No. of voluntary donors
Adverse Event Following Immunization Blood Typed
Anthrax
Human Avian Influenza Have previously donated blood
Measles HEALTH EMERGENCY MANAG
Meningoccoal Disease Is your Local Government Health Facility
Neonatal Tetanus with DRRM-H Plan ?
Paralytic Shellfish Poising with trained and equiped health emergency
managers and responders
with commodities?
Rabies
Severe Outbreak/Cluster of disease with Operation Center?
Malaria Is your Local Government Health Facility with Institutiona
NOTE: If Yes= 1, NO=0 DRUGS ABUSE PREVENTION
DANGEROUS
Unusual disease of threats. Specify
No. of person who used drugs
No. of person who used drugs screened
ENVIRONMENTAL H
No. of Households
Households with access to improved or safe water supply
Households using safely managed drinking water
Households using safely managed sanitation
 No. of barangays
No. of barangays declared as ZOD
Overall Issues and Concerns:
 LOCAL HEALTH SYSTEM

ed
tures

functional EMR
tio of 1:20,000
atio of 1:20,000
atio of 1:20,000
edicated public health worker

hilhealth
RAC
dited BHW's (rendered 3yrs and above

masterlist
W Incentive to registered and accredited BHW

man resource at GIDA/ICCs - IPs

d
ered health services
s for IP health programs and activities in the
alth programs/activities in the LIPH
TWORK (SDN)
ities
on
tation of the health facility
name and exact location

ONAL VOLUNTARY BLOOD SERVICES PROGRAM

YES NO
ood
EALTH EMERGENCY MANAGEMENT SYSTEM
Health Facility

d health emergency bv

Health Facility with Institutionalized DRRM-H?

RUGS ABUSE PREVENTION ANDN TREATMENT PROGRAM
ugs
ugs screened
ENVIRONMENTAL HEALTH

improved or safe water supply

anaged drinking water
anaged sanitation
as ZOD
 PROGRAM - BASED SERVICE DELIVERY MONITORING TOO
Province of: PANGASINAN

Municipality of: BAYAMBANG Inclusive dates of reporting: O

FAMILY HEALTH
A. Maternal Health

Pregnant Women/ mothers

10-49 y/o 10-14 y/o 15-19y/o

pregnant tracked/ seen OLD Number of clients (25 yrs. old & ab

NEW screened using PhilPEN

pregnant with birth plan # of clients w/ raised BP (accordin

pregnant w/ 4ANC # of clients given DOH maintenanc

pregnant w/ missed ANC # of patients overwieght/ obese

pregnant given vitamins (specify) # of high risk adults (>30% CVD ris

Deliveries # of clients reffered

Post partum women with 2 PPV # of clients followed up (monthly)

Live births
Number of maternal death/s
Number of neonatal death/s
Number of infant death/s Number of clients (25 yrs. old & ab
Number of under five death/s Clients w/ raised BS

Stiilbirths Clients given DOH maintenance m

Issues
Clients referred
Clients followed - up

B. National Immunization Program

No. of children (0-11mos)

vaccinated missed
vaccination Issues # of women referred for papsmea
per antigen per antigen # of women undergone BE (SBE)
BCG # of patients w/ mass (all forms)
Hepa B (<24hrs)
Hepa B (>24hrs)
PENTA 1
Current smokers
PENTA 2

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PENTA 3
OPV 1
OPV 2 No. of clients experiencing painful

OPV 3 No. of clients referred

IPV
PCV1
PCV 2
No. of individual with enlarged ne
PCV 3
MCV 1
MCV 2
Infants w/out vaccination in all antigens
C. Newborn Screening Program
No. Issues Clients mentally disturbed
Newborn without NBS 0 Clients referred
D. Nutrition Program
1st Sem 2nd Sem
Issues
(Jan-June) (Jul-Dec) Number of PWDs
PWDs referred for possible provisi
No. of underfive weighed and height measured
PWDs provided with assistive devi
Underweight children
stunted children
wasted children
E. Family Planning Program Patients referred based on Snellen
served w/fp Patients w/ visual impairement (an
No. Issues
commodity
Clients referred
CU (end) in all methods
Unmet needs (NHTS) tracked
Unmet needs (NON-NHTS) tracked Senior Citizen
New acceptors of modern FP methods through post
partum FP (PPIUD) SC provided with at least 2 health
New acceptors of modern FP methods through outreach
missions

New acceptors of modern FP methods provided in

regular public healtth facilities

Total no. of new accpetor for modern FP No. of patients needing surgery
No. of served (provided with FP commodities) No. of patients assisted by NDPs
F. Oral Health

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 given dental
No. services Issues

Children seen referred for Dental NHTS provided with annual health
Check up Non -NHTS porovided with annua

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ERY MONITORING TOOL (For HRH) version 4
e of: PANGASINAN
usive dates of reporting: OCTOBER 1 - 31, 2018 Morbidity week: _________
LIFESTYLE-RELATED DISEASE
A. HYPERTENSION
Number Issues

Old cases New cases

er of clients (25 yrs. old & above)

ed using PhilPEN
ents w/ raised BP (according to PhilPEN)
ents given DOH maintenance meds
tients overwieght/ obese
gh risk adults (>30% CVD risk)
ents reffered
ents followed up (monthly)

B. Diabetes Mellitus
Number Issues
Old cases New cases
er of clients (25 yrs. old & above) screened using PhilPEN
w/ raised BS

given DOH maintenance meds

referred
followed - up
C. Cancer
Number Issues
Old cases New cases

omen referred for papsmear/ VIA (age)

omen undergone BE (SBE)
tients w/ mass (all forms)
D. COPD
Number Issues

t smokers

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 E. Kidney Disease
Number Issues
clients experiencing painful/difficulty in urination

clients referred
F. Thyroid
Number Issues

individual with enlarged neck mass

ESSENTIAL NON-COMMUNICABLE DISEASES

G. Mental Health
Number Issues
Old cases New cases

mentally disturbed
referred
H. Person with disability
Number Issues
er of PWDs
referred for possible provision of assistive device
provided with assistive devices

I. Blindness
Number Issues

ts referred based on Snellen chart assessment

ts w/ visual impairement (any form)

referred
J. Senior Citizen
Number Issues

Citizen

vided with at least 2 health services

K. Surgical Caravan

Number Issues

patients needing surgery

patients assisted by NDPs
L. Profiling

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 Number Issues
provided with annual health check-up
NHTS porovided with annual health check-up

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 INFECTIOUS DISEASE
A. Dengue
Number Issues
Referred Not referred

Suspect cases

B. Malaria
Number Issues
Referred Not referred

Suspected cases with fever and chills

C. Rabies
Number Issues
Referred Not referred

Animal bites
Animal bites for vaccination
Clients completed vaccination
D. Schistosomiasis
Number Issues
Referred Not referred

Number of eligible population

Yellowish discoloration and/or enlarged
abdomen in endemic area
Endemic population subject to stool
examination at least 2x a year
E. STH deworming

# dewormed Not referred Issues

1-4 years old

5-12 years old
13-18 years old
* Additional: Masterlist of 1-4 years old and 5-18 year old (OSY) Kindly
refer to the attachment at the back

F. Leprosy
Number Issues
Referred Not referred

Suspected cases for confirmation

G. Tuberculosis
Number Issues

Present TB cases
2 weeks cough
Cases referred
(+) Sputum exam
(+) Xray
(+) GeneXpert
Contact tracing

Defaulter tracing

Completed treatment (6mos)

Prepared by: Approved by:

NORMIN T. VELASCO, RN DRA. PAZ F. VALLO

(Name of HRH) (Name of MHO)
 LOCAL HEALTH SYSTEM

NHTS
Individuals Issues
# of IP's profiled

# of Ip's rendered health services

REGIONAL EPIDEMIOLOGY & SURVEILLANCE UNIT

Number Issues

Food borne/waterborne illnesses

Chemical Poisoning
MERSCov person under investigation

Maternal Death (Direct Cause)

Noitifiable Diseases/Syndromes under Category 1 (Immediately Notifiable):

Acute Flaccid Paralysis

Anthrax
Adverse Effect Following Immunization
Human Avian Influenza
Measles
Meningococcal Disease

Neonatal Tetanus

Paralytic Shelfish Poisoning

Rabies
Severe Acute Respiratory Syndrome
(SARS)
Outbreaks/ Clusters of diseases

Malaria

HEALTH EMERGENCY MANAGEMENT SYSTEM

Conduct RHA during emergencies and
disasters
Conduct SPEED during emergencies and
disasters

No. of household with at least 1 member

trained on CPR

Noted by:

JOANNE A. VILLANUEVA
(Name of DMO)
MAMANTA, ZAIJAH JACOB NO M 01/17/2014
SALINAS, KYLE NO F 03/30/2014
MAGARRO, MARY ROSE NO F 05/19/2014
CABATBAT, JASMINE NO F 05/25/2014
SIMEON, JASCHE KIAN NO M 06/06/2014
FLORENDO, JOHN ALEJANDRO NO M 08/01/2014
TAPIADOR, LLOYD FRANCIS NO M 08/05/2014
GARCIA, MAICA NO F 08/09/2014
SAMSON, MARY JANE NO F 08/17/2014
QUIRANTE, HAROLD NO M 08/27/2014
BAUTISTA, ELLEN JOY NO F 09/09/2014
CABATBAT, SUNSHINE NO F 09/12/2014
BAUTISTA, CATHRINA MAE NO F 09/25/2014
MENDOZA, MARK VINCENT NO M 09/25/2014
VALDOZ, AYESHA REIGN NO F 09/26/2014
GALISIM, SUNSHINE NO F 10/04/2014
BANCOLITA, MYRA JANE NO F 10/11/2014
BAUTISTA. SHANTELL NO F 10/17/2014
DE GUZMAN, ARJAY NO M 10/24/2014
BAUTISTA, NIKKI GRACE NO F 10/25/2014
DELOS SANTOS, JESIAH CRISIA NO F 10/30/2014
JUNIO, JHON IAN NO M 12/04/2014
MAGARRO, ALYSA NO F 12/21/2014
BANCOLITA, JYLYN NO F 01/01/2015
CARANTO, JIANA MAE NO F 01/04/2015
JASON, PARIS JAN NO M 01/07/2015
ELMAGA, NATHANIEL FRANCIS NO M 01/20/2015
GARCIA, SABRINA JERMAINE NO F 03/26/2015
PABITO, JENZEL ANNE NO F 04/10/2015
BENE, RAVEN BENIDECT NO M 04/16/2015
DELA CRUZ, EMIL ROSS NO F 05/06/2015
PATAYAN, LADY KIMBERLY NO F 05/09/2015
RESULTAY, JANINE NO F 05/17/2015
MANLUNGAT, LANCE KENNETH NO M 05/30/2015
AGBUYA, NICKAELLA IVY NO F 06/21/2015
REBAGODA, JOYRICH NO F 06/29/2015
MENDOZA, RUZZELL RAIVEN NO M 07/20/2015
PATAYAN, ARYAN NO F 08/09/2015
BUGARIN, HANZ MICKAEL NO M 08/10/2015
BAUTISTA, MICHAELLA NO F 08/21/2015
ALLADO,MARCUS GABRIELLE NO M 09/08/2015
VALENCIA, RAIVEN JOSHUA NO M 09/11/2015
TAPIADOR, ANGEL SHANTELL NO F 09/15/2015
OJERA, DENZEL MHIKE NO M 10/02/2015
DUEñAS MIKE JAREN NO M 10/06/2015
ENONG, FAYE RHUSSEL NO F 10/20/2015
MIñA, ZIAN JADE NO M 10/20/2015
QUIRANTE, EBRON NO M 11/05/2015
DE VERA, REGINE NO F 11/18/2015
AQUINO, DEXIE JOIANA NO F 12/20/2015
PATAYAN, JOHN CHRISTIAN NO M 12/24/2015
VINOYA, JOSHUA NO M 12/26/2015
BAUTISTA, GHEMICA NO F 12/27/2015
FERRER, VINCE XYLER NO M 01/03/2016
GARCIA, RONALDO NO M 01/04/2016
DELOS SANTOS, JUN CEDRICK NO M 03/20/2016
VALDOZ, ZWIZZA REIGN NO F 04/16/2016
CARANTO, CARL NATHANIEL NO M 04/19/2016
FERNANDEZ, ALTHEA NO F 04/29/2016
VILLANUEVA, LYZA MAE NO F 05/07/2016
TARLINO, JACOB NATHAN NO M 06/03/2016
GARCIA, DANIEL NO M 09/09/2016
SABANGAN, PRINCE PHILIP NO M 09/26/2016
QUIGAO, JAMILA JOY NO F 10/01/2016
SALVADOR, JELLIAN SAM NO F 10/20/2016
JUNIO, JAMES NO M 10/30/2016
BAUTISTA, SHEH IAH NO F 11/18/2016
DE GUZMAN, JESSICA NO F 12/14/2016
CABATBAT, KRISTEL JOY NO F 12/18/2016
ANGELITO, JADE THERICE NO F 01/23/2017
VELASCO, JEMZEUS NO M 01/30/2017
DIOLA, JEANELLE ANNE NO F 01/30/2017
JASON, IRISH ANN NO F 02/05/2017
ESTABILLO, FAITH RHUSEL NO F 02/22/2017
JUNIO, JAY-JAY NO M 03/01/2017
ALLADO, MARCELA GWEN NO F 03/08/2017
SAMSON, ANA NO F 03/12/2017
BANCOLITA, JELLIAN NO F 03/14/2017
SUMAGPAO, ELISHA ABBEY NO F 03/22/2017
ADDUN, CHAD LENE NO F 04/30/2017
DELA CRUZ, XYRUS NO M 07/16/2017
HONRADO, BRIANNA KEISHA NO F 07/29/2017
VELASCO, AISHA NO F 08/17/2017
VIRAY, KIAN NO M 09/02/2017
AQUINO, DREX JACOB NO M 11/04/2017
AQUINO, MADISON LANA NO F 11/04/2017
CENTINO, ROLANDO NO M 12/05/2017
REBAGODA, JHAY MARK NO M 12/13/2017
SABANGAN, EDEN JOY NO F 12/17/2017
PATAYAN, AYESHA NO F 12/24/2017
SAGUN, DANIEL NO M 01/10/2018
ROMERO, CHRISTINE NO F 01/10/2018
PATAYN, ATHENA NO F 01/31/2018
CABATBAT, JOANA CRIS NO F 03/03/2018
 Number of Notifiable Diseases/Syndromes reported to PESU per week

Quarter 1 Quarter 2 Quarter 3 Quarter 4

MW 1 0 MW 14 0 MW 27 0 MW 40
MW 2 0 MW 15 0 MW 28 0 MW 41
MW 3 0 MW 16 0 MW 29 0 MW 42
MW 4 0 MW 17 0 MW 30 0 MW 43
MW 5 0 MW 18 0 MW 31 0 MW 44
MW 6 0 MW 19 0 MW 32 0 MW 45
MW 7 0 MW 20 0 MW 33 0 MW 46
MW 8 0 MW 21 0 MW 34 0 MW 47
MW 9 0 MW 22 0 MW 35 0 MW 48
MW 10 0 MW 23 0 MW 36 0 MW 49
MW 11 0 MW 24 0 MW 37 0 MW 50
MW 12 0 MW 25 0 MW 38 0 MW 51
MW 13 0 MW 26 0 MW 39 0 MW 52

Masterlist of 1-4 years old and 5-18 years old Out of School Yout
Name Birthday Age Address Name

(First Name, MI, Last Name) (mm/dd/yyyy) *in years (Barangay) (First Name, MI, Last N

BALANI,JAMILLA KAI 10/24/2012 ZONE III

5
BALANI, JEM KYLE 01/16/2016 4 ZONE III

BOBIS,RHEEYAN ELOIJAH 09/06/2015 ZONE III

3
TAMONDONG,JAMILLA 08/12/2017 ZONE III
6
TAMONDONG,JOAQUIN 12/08/2015 ZONE III
6
JUNIO,ANGEL 12/25/2014 ZONE III
4
PEREZ,CALEX JAVIER 08/26/2013 ZONE III
6
PEREZ,YUAN JESS 09/20/2015 ZONE III
2
BALADOREZ,KAL EL 07/22/2015 ZONE III
7
PEREZ,BINCH VINCENT 10/04/2017 ZONE III
3
BOQUIREN,FLOREAH JUDE 11/29/2013 ZONE III
2
PINLAC,MC. DENVER 12/18/2014 ZONE III
2
SAMSON,RYSH WAYNE 03/18/2014 ZONE III
4
SAMSON,RYSH RYAESHA 01/15/2016 ZONE III
2
BATO,JOSSAIA 03/03/2013 ZONE III
3
JASMINES,PRINCE KHEN 03/21/2012 ZONE III
4
TULA RAMA,NICHOLO THEO 12/02/2015 ZONE III
1
TAGULAO,PHEO LEE 08/13/2013 ZONE III
2
TAJEDA,EDELYN 02/06/2015 ZONE III
1
TAJEDA,LOVELY JOY 01/06/2014 ZONE III
5
JUNIO,JEWEL 09/10/2012 ZONE III
2
CAPARAS,KEN LOUS 07/23/2012 ZONE III
5
DE GRACIA,KYRIE RODEL 11/02/2015 ZONE III
2
DE VERA,MARIE YSABELLE 09/12/2017 ZONE III
5

Page 2
TAMONDONG,JACOB 08/26/2016 ZONE III
2
MONTEMAYOR,LEONARDO 02/17/2017 ZONE III
1
TEJADA,JOEL 10/10/2017 ZONE III
2
MAGALONG KRISTEL 07/01/2014 ZONE III
1
JOEL BASILAN 03/25/2017 ZONE III

CURACHEA STEVEN BRYLE 10/10/2017 ZONE III

CAMACHO ERICA 03/05/2016 ZONE III

GARAY ARIEL LUIS 09/04/2012 ZONE III

BABY CECELIA PEREZ 03/03/2018 ZONE III

ROLLIE GAMBOA 02/27/2018 ZONE III

VILLANUEVA BABY DIANNE 02/26/2018 ZONE III

CLAUDIO BABY GIRL 03/06/2018 ZONE III

ABALOS BABY BOY 04/16/2018 ZONE III

LOPEZ BABY GIRL 04/11/2018 ZONE III

Page 2
o PESU per week (27 N.D.)

Quarter 4 Issues
0
0
0
0
0
0
0
0
0
0
0
0
0

ut of School Youth
Name Birthday Age Address

t Name, MI, Last Name) (mm/dd/yyyy) *in years (Barangay)

Page 2
Page 2