REPUBLIC OF KENYA – MINISTRY OF HEALTH
COMMUNITY HEALTH WORKERS SERVICE DELIVERY LOG BOOK:
MOH 514
NAME OF CHU: COUNTY:
MCUL CODE: SUB COUNTY:
LINK FACILITY: DIVISION:
NAME OF CHW: LOCATION:
SUB-
LOCATION:
Start Date: End Date:
OOK:
ABOUT THE SERVICE DELIVERY LOG BOOK
Description: The Service Delivery Log Book is a diary that is used to collect information from the household during the period of offering a health service, health messag
. The household register gives the denominators for measuring the effort of the care giver
What type of The basic information collected is factual, based on what was done or identified in the household and for individual (s) in the households served.
information
collected?:
Who should
fill or
complete The LOG measures the actual CHW's effort and should be written or filled during the household visitation.
the LOG
BOOK and
what to
measure?
When and to
whom
should the
LOG BOOK At the end of every Month (preferably 28th to 30th ), the Log Book should be submitted to the CHEW for summarization
be
submitted
to?
ce, health messages and during defaulter tracing
# WHAT IS IN THE COLUMN? AN EXPLANATIONS ON HOW TO RECORD IN THE REGISTER
Record the date when the household member receives a service from a
A Date Community Health Worker (recorded as Date:Month:Year) for example,
11/10/2013
Record the name of the village where the household is located
B Village Name
This is a unique identification number, which is assigned to a household during
C Household Number. registration
Record the number of pregnant woment referred by Community Health Worker
D Pregnant women referred for ANC (CHW) for Ante Natal Care (ANC) in that household
Record the number of pregnant woment counseled on Individual Birth Plan (IBP)
E Pregnant women counseled on IBP from the household
Mothers with newborns counseled on Record the number of mothers with newborns counseled on Exclusive Breast
F Feeding (EBF)
EBF
Home deliveries referred for PNC Record the number of home deliveries referred by CHW for Post Natal Care
G (PNC) Services
Services.
Number of women (15-49yrs) provided Record the number of individuals provided with Family Planning (FP)
H commodities by CHW
with FP commodities by CHWs
Children of 0-11 months referred for Record the number of children of 0-11 months age referred for immunization
I services
immunization
Children 0-59 Months participating in Record the Number of children aged 0-59 Months participating in GMP
J
growth monitoring activity.
Children 6 - 59 Months referred for Record the number of children between 6 months of age to 59 Months (5 years )
K referred for Vitamin A supplementation .
Vitamin A supplementation
Children 0-59 months referred within 24 Record the number of children below 5 years referred to health facility within 24
L hours of onset of illness (e.g fever, hours of onset of illness (fever, diarrhea)
diarrhoea)
Children 6- 59 Months with MUAC Record the number of children of 6-59 months with severe malnutrition - mid
M upper circumfrence MUAC Tape mneasure is red (< 11.5cm)
indicating (Red) severe malnutrition.
children 6- 59 Months with MUAC Record the number of children of 6-59 months with moderate malnutrition- mid
N indicating (Yellow) moderate upper circumfrence is yellow (< 12.5cm)
malnutrition.
Children of 0-59 months with malnutrition Record the number of children under of 0-59 months with severe and moderate
O
referred malnutrition referred for management
Cases of chronic illness referred Record by indicating the number of a case of individuals with a particular
1=Diabetes,2=Cancer, 3=Mental chronic illness or cough for more than two weeks and referred to a health
P facility.
Illness,4=Hypertension,5=Chronic
Respiratory Diseases
Cases of cough more than 2 weeks Record the number of a case of individuals with chronic cough for more than two
Q weeks indentified and refffered to a health facility.
referred
Record the Number of Households with Functional Pit Latrines. ( Latrines
R Households with functional latrine In Use).
Record number of Households with hand washing facilities ( Tippy Tap,
S Households with handwashing facilities leaky Tin)
Record Households Using treated water for drinking
T Households using treated water
Record the number of pregnant women who delivered under skilled
U Skilled birth attendant attendant
Elderly people (60 +)referred for health Record the number of elderly people aged 60 years and above referred to a
V health facility for check - ups
check - ups
TB treatment defaulters traced and Record the number of Tuberculosis (TB) defaulters traced and referred to a
W health facility.
referred
Record the number of ART defaulters referred to a health facility
X ART defaulters referred
Record the number of ANC deafulters referred to a health facility.
Y ANC defaulters referred
Record children under five years of age who defaulted on
Z Immunization defaulters referred immunization but have been traced and reffered for immunization.
Record the number of individuals referred for HIV Counseling and Testing (HCT)
AA Individuals referred for HCT
Pregnant women refered for skilled Record the number of pregnant women referrred for skilled delivery.
AD
delivery
Chronic ill patients provided with home Record the number of chronic ill patients provided with Home Based Care (HBC)
AB
based care
Record the number of Children aged 2 - 14 years of age dewormed
AC Children 2-14 years dewormed
Newborn visted at home within 48 hours Record number of newborns visited within 48 hours of birth,
AE
of delivery
Transfer to HH register
Transfer to HH register
A
Date
B
Village Name
TOTAL
Number of Community Action Days held
C
Number of Community dialogue days held
Household Number
Pregnant women referred
D
for Ante Natal Care
(ANC)
Pregnant women
E
counseled on Individual
Birth Plan (IBP)
Mothers with newborns
counseled on Exclusive
F
Breast Feeding (EBF)
Home Deliveries
G referred for Post Natal
Care (PNC)
Number Services
of women (15-
49yrs) provided with
H
Family Planning (FP)
commodities by CHWs
Children 0-11 months
I
referred for
immunization
Children 0-59 Months
J
participating in growth
monitoring
Children 6 - 59 months
K
referred for Vitamin A
supplementation
Children 0-59 months
referred within 24 hours
L
of onset of illness
fever/Hotness of the body
Children 0-59 months
referred within 24 hours
of onset of illness
diarrhea
Children 0-59 months
referred within 24 hours
of onset of illness (cough
and fast breathing or
Pneumonia)
Children 0-59 months
treated within 24 hours
of onset of illness for
fever/hotness of body
Children 0-59 months
treated within 24 hours
of onset of illness for
diarrhea
Children 0-59 months
referred within 24 hours
of onset of illness for
cough and fast breathing
or Pneumonia
Children 6- 59 Months
with MUAC indicating
M
(Red) severe
malnutrition
Indicators
Children 6-59 months
CHW TREATMENT AND REFERRAL OF CHILDHOOD ILLNESSES
with MUAC indicating
N
(Yellow) moderate
malnutrition
Children of 0-59 months
O
with malnutrition
referred
Cases of chronic illness
P
referred
1=Diabetes,2=Cancer,
COMMUNITY HEALTH WORKERS SERVICE DELIVERY LOG BOOK
3=Mental
Cases of cough for 14
Illness,4=Hypertension,5
days or more referred
Q
=Chronic Respiratory
Diseases
Households with
R
functional latrines
S
Handwashing facilities
T
Treated water
Households with water
treatment commodities
available on day of visit
U
Skilled birth attendant
Elderly people (60
V
+)referred for health
check - ups
Tuberclosis treatment
W
defaulters referred
X
ART defaulters referred
Y
ANC defaulters referred
Immunization defaulters
Z
referred
Individuals referred for
AA
HCT
Pregnant women refered
AB
for skilled delivery
Chronic ill patients
provided with home
AC
based care
Children 2-14 years
AD dewormed
Newborn visted at home
within 48 hours of
AE
delivery
Remarks
