Facility Level SOP

Standard Operating Procedure for District Health Management Information System (DHMIS): Facility level
DISTRICT HEALTH
MANAGEMENT
INFORMATION SYSTEM
Standard Operating Procedures Facility Level Updated Edition December 2016
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DISTRICT HEALTH MANAGEMENT INFORMATION SYSTEM (DHMIS)
Standard Operating Procedures

Facility Level
Updated Edition
December 2016
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FOREWORD BY THE DIRECTOR-GENERAL
In July 2011, I approved the District Health Management Information

Systems (DHMIS) Policy for South Africa, which is aimed at ensuring
uniformity in the implementation of the DHMIS across the country. I
also indicated then, that a need exists for the development of Standard
Operating Procedures (SOPs), to guide the implementation of the policy.
Since the first edition of the SOPs for Health Facilities in November 2012, a
number of developments have taken place and new policy decisions were
taken. During 2012 we initiated the process to rationalise the number of
registers that are used in health facilities. In 2016 the new standardised
PHC Comprehensive Register was fully roll-out in PHC facilities in eight
provinces. The Health Patient Registration System (HPRS) to register
clients attending PHC facilities together with a standardised filing system
were introduced. These initiatives are helping to reduce long waiting times
amongst others.
The HPRS has been rolled-out in the National Health Insurance pilot
districts and currently being scaled up in the remaining districts. During
2016, the National Indicator Data Set (NIDS) was successfully revised and 2017 NIDS was approved for implementation
from 1 April 2017. The web-DHIS transition strategy was also approved in 2016 and country-wide training workshops
were also done.
It is for the above developments that the Standard Operating Procedures for the DHMIS Policy were updated. Particularly,
we have revised the data flow timelines and stipulated additional procedures to strengthen the quality of the routine
health data. The data submission timelines have now been reduced from 60 to 25 days in the updated SOPs.
This updated edition sets out SOPs for the DHMIS policy, for use by health facilities, which are the first level of interaction
between community members and health services. Health facilities are therefore the first point of data collection and the
level at which data quality must first be improved. Health facility SOPs have thus been prioritised for publication. These
SOPs seek to achieve standardisation in data collection, capturing, collation, storage, analysis and transmission to
other levels of the health system. Related SOPs have been produced for other levels of the public health sector namely:
Health sub-districts; districts; provinces and the National DoH.
These SOPs present basic and practical steps to be followed by health care providers and health information
management personnel to ensure that data is appropriately handled and used to improve service delivery at local level,
prior to submission to the next level of the health system, within the specified time frames.
The long-term vision of the National Department of Health is the creation of a national integrated patient-based
information system, which will require implementation of electronic systems for data management at all levels of
the health system. In this regard, in April 2014, the Department published the National Health Normative Standards
Framework for Interoperability in eHealth in South Africa through a Gazette Notice. This was followed by an assessment
of all Patient Health Information Systems for Health Care (PHC) by the Centre for Scientific and Industrial Research
(CSIR). The CSIR was thereafter commissioned to conduct an assessment of all Hospital-based Patient Information
Systems which is expected to be completed in 2017.
All health facility managers in the public health sector should ensure implementation of these SOPs. They must be
assisted in this role by information officers from health sub-districts; districts; provinces and the National Department of
Health.
I wish to acknowledge and appreciate the pivotal role played by Health Information Systems Programme, Health
Systems Trust and Measure Evaluation Strategic Information for South Africa in assisting the Department with the
revision of these SOPs.
_____________________________
MS MP MATSOSO
DIRECTOR-GENERAL
NATIONAL DEPARTMENT OF HEALTH
DATE:
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LIST OF ABBREVIATIONS
ART Antiretroviral Therapy

CHC Community Health Centre
CHIP Child Healthcare Problem Identification Programme
DG Director-General
DHER District Health Expenditure Review
DHIS District Health Information System
DHMIS District Health Management Information System
DHP District Health Plan
DoH Department of Health
ETR Electronic Tuberculosis Register
HIS Health Information System
HOD Head of Department
ICT Information and Communication Technology
IT Information Technology
M&E Monitoring and Evaluation
NCS National Core Standards
NDD National Data Dictionary
NDoH National Department of Health
NHISSA National Health Information Systems Committee of South Africa
NIDS National Indicator Data Set
OPD Outpatient Department
Org unit Organisational Unit
PEC Patient Experience of Care
PHC Primary Health Care
PIDS Provincial Indicator Data Set
PPIP Perinatal Problem Identification Programme
PQRS Provincial Quarterly Reporting System
QRS Quarterly Reporting System
SOP Standard Operating Procedure
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DEFINITIONS
TERMINOLOGY OPERATIONAL DEFINITION

Accuracy Also known as validity. Data is measured against a referenced source and found to be
correct. Accurate data minimize error (e.g. transcription error) to a point of being negligible
Completeness Data are present and usable and represent the complete list of eligible sources and not just
a fraction of it
Confidentiality Assurance that data will not be disclosed inappropriately and treated with appropriate
levels of security
Data Raw, unprocessed numbers
Data collation The process where data for a data element from various service points are added together.
It is very important to ensure that during this process the responsible person add the data
correctly together and avoid arithmetic errors
Data input forms This refers to the final form which will be used to enter the data into the relevant database
Data sign off Data sign off refers to the process where the person with the required authority agree
to the correctness and validity of the data and commits him or herself to submit data in
accordance with data flow guidelines
Indicator A quantitative or qualitative variable that provides a simple and reliable measurement of
one aspect of performance, achievement or change in a program or project
Information Processed or analysed data that adds context through relationships between data to allow
for interpretation and use
Integrity System used to generate data is protected from deliberate bias or manipulation or loss of
Line manager A line manager has several management responsibilities, including direct management of
employees, administrative management and functional management. For an example, a
person who directly manages a health facility reports to an area manager.
Organisational Unit Organisational Unit means reporting levels used in South African public health system (e.g.
(Org Unit) org unit 5 is a facility level)
Parent facility The facility in the organisation unit which takes responsibility for one or more facilities.
Precision Data has sufficient detail and is free as far as possible of error in terms of under and/or
over reporting
Programme manager Manager responsible for a specific health programme/s e.g. (HIV and AIDS, Nutrition etc.)
Reliability Data generated by an information system is based on protocols and procedures that do not
change according to who is using them or how often they are used. Data is measured and
collected consistently
Service point Reporting units within a facility e.g. consultation rooms, services within facility, hospital
wards (OrgU6)
Source point Facility level e.g. hospital, PHC clinic, delivery facility (OrgU5 levels)
Timeliness Data and information is available on time for meeting budgeting, monitoring, decision
making and reporting requirements
Users of data Stakeholders who are authorised to access and use data in DHIS for monitoring,
evaluation, research and reporting purposes
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TABLE OF COTENTS
LIST OF ABBREVIATIONS............................................................................................................................. 4
DEFINITIONS.................................................................................................................................................. 5
1. Introduction 9
1.1 Purpose 9
1.2 Scope 9
1.3 Training 9
1.4 Background 9
1.5 Principles 10
2. DATA/INFORMATION MANAGEMENT 11
2.1 Responsibility 12
2.1.1 Health Facility Receptionist/Patient Registration Staff
(PHC facilities and hospitals and non-facility based services) Responsibilities 12
2.1.1.1 Procedure: Health Facility Receptionist/Patient Registration Staff............................................. 12
2.1.2 Health Care Provider Responsibilities 13
2.1.2.1 Procedure: Health Care Provider............................................................................................... 14
2.1.3 Data Capturers Responsibilities 15
2.1.3.1 Procedure: Data Capturer.......................................................................................................... 15
2.1.4 Health information officer responsibilities 18
2.1.4.1 Procedure: Health Information Officer........................................................................................ 18
2.1.5 Facility Manager’s responsibilities 22
2.1.5.1 Procedure: Facility Manager..................................................................................................... 23
3. Reference Documents 27
4. ANNEXURES 28
4.1 List of registers/data collection tools 28
4.1.1 PHC facilities 28
4.1.2 Hospitals 28
4.1.3 PHC facilities and hospitals 28
4.1.4 Ward based PHC outreach (WBPHCOT) teams 28
4.1.5 Sexually transmitted infection (STI) sentinel sites: 29
4.2 Guidelines to completing registers 29
4.2.1 PHC Reception Headcount Register 29
4.2.2 Comprehensive Tick Register and forms for PHC facilities,
hospitals, WBOT and School health services 30
4.3 Weekly Tally Summary and Monthly Tally Notepad 31
4.3.1 Weekly Tally Summary 31
4.4 Data Quality Checklist: FACILITY MANAGER CHECKLIST:
PRE-SUBMISSION DATA VALIDATION 32
4.5 Facility Data Sign-off form 34
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1. Introduction
1.1 Purpose
This document provides Standard Operating Procedures (SOPs) to ensure appropriate data and information management
at health facilities. These SOPs are an updated version of the 2012 SOPs. These Standard Operating Procedures aim
to clarify the responsibilities and procedures for effective management of aggregated routine health service data.
1.2 Scope
These Standard Operating Procedures are mandatory and shall be implemented by all employees and contractors
when engaging in health information related activities for Department of Health facilities. System and non-facility based
services’ specific SOPs must be aligned to the DHMIS SOPs. These SOPs must be used in conjunction with the
following:
• DHMIS Policy 2011
• National Indicator Dataset (NIDS)
• System and Service Specific SOPs
• Reference Documents listed in Section 3
1.3 Training
The Facility Manager must ensure that team members (facility based and non-facility based staff reporting to facility) who
follow these procedures understand these Standard Operating Procedures’ objectives and other inter-related activities.
The Facility Manager must ensure that team members sign that they have read and understand these SOPs. Records
of training provided on the SOPs must be retained within the facility.
1.4 Background
In terms of the National Health Act (Act 61 of 2003) the National Department of Health (NDoH) is required to facilitate and
coordinate the establishment, implementation and maintenance of health information systems at all levels. The District
Health Management Information System (DHMIS) Policy 2011 defines the requirements and expectations to provide
comprehensive, timely, reliable and good quality routine evidence for tracking and improving health service delivery.
The strategic objectives of the policy are to strengthen monitoring and evaluation (M&E) through standardization of
data management activities and to clarify the main roles and responsibilities at each level for each category of staff to
optimize completeness, quality, use, ownership, security and integrity of data.
Since 2000 the NDoH has been using various systems to collect and manage routine health service based information.
These include the DHIS, TIER.net and ETR.net. In 2015, a Health Patient Registration System (HPRS) was rolled
out in Primary Health Care Facilities and the Web-DHIS will be gradually phased in. There is progressively more
focus on implementing electronic systems that are meeting the criteria of Health Normative Standards Framework for
Interoperability in eHealth in South Africa.
1.5 Principles
The following principles should be kept in mind when these SOPS are implemented:
1. Health service data elements are collected by means of a standardised set of rationalised registers (refer to list
of registers in the addendum). Those registers used for recording data elements are updated in line with the
relevant policies and guidelines. Data collection tools should have space for the following:
• Facility name and facility code (as in Master Facility List), year and register number
• Start date of register
• End date of register
• Register pages must be pre-numbered
2. Data collection tools and processes for mobile and satellite clinics as well as health posts and outreach teams
must be managed in the same manner as those for fixed facilities. Summary forms must be submitted to the
manager of the ‘parent’ fixed facility to be captured into the DHIS.
3. Service points should be allocated appropriate Organisational units.
4. Facilities employ data capturers/ward clerks to enter data into the various systems. Specific SOPs have been
developed to guide data capturing into each of these systems and are therefore not covered in this document.
Facilities capturing data into these systems must have copies of these SOPs and adhere to them.
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5. The following are crucial for monitoring and optimising data quality:
• Standardised activation of relevant data elements of each health care facility
• Standardised use of 0 (zero) reporting irrespective of the DHIS capturing level (facility or sub-district) or
frequency (daily or monthly)
• Facility must always be ready for an audit
6. Each health care user should have a facility retained clinical record in which all services are recorded in line with
the guidelines of statutory body.
7. All clinical records, data collection and collation tools must be stored safely and access to them controlled at all
times.
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2. DATA/INFORMATION MANAGEMENT
This data flow diagram provides the timelines to ensure that routine data submission and feedback are met. The
timeframe for data flow from facility though to NDoH is 20 days.
2.1 Responsibility
2.1.1 Health Facility Receptionist/Patient Registration Staff (PHC facilities and hospitals and non-facility based
services) Responsibilities
Some large facilities have dedicated reception staff, but all staff providing a service to patients is responsible for the
procedures relevant to patient files and headcounts. The administrative staff assigned to reception and filing must
manage records at reception and the records storage room. They must ensure access control to medical records and
the confidentiality of patient information is maintained at all time.
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2.1.1.1 Procedure: Health Facility Receptionist/Patient Registration Staff

Step Action
ON A DAILY BASIS
PATIENT ADMINISTRATION
Register the patient visit in the system in use
Double check whether a patient file is available before a patient is registered as a new patient to prevent duplicates being issued
Retrieve patient file from the filing cabinet or issue new patient file
Issue and record all folders issued per day
No patient should be seen by a health care provider without a file except in emergencies
The patient file must be issued as soon as possible in these exceptional cases
Record the visit as a headcount each time a patient presents to the facility for any service in the Reception/OPD/Emergency Head-
count register before the patient file is handed to health care provider
Count each patient as a headcount once each day, regardless of the number of services provided to the individual at the facility on
that day
Start each day with a new page of the Headcount Register
In small facilities where not many patients are seen, one line in the Headcount Register can be left open after totalling that day’s
headcount
The new date can be written in the middle of the next row
Ensure that no patient files leave the facility
Monitor return records and track outstanding records
Record, track and recover loaned/removed records
If a patient is transferred to another facility a letter of transfer and copies of relevant records should accompany the patient to the
referred facility
The original file remains in the referring facility
Make follow up appointments for patients and provide appointment cards or dates
Ensure access control of medical records and the confidentiality of patient information is maintained at all times
Non-facility based services should use the prescribed data collection tool for headcounts
Submit the register to the data capturer/ward clerk for capturing/summarising once it has been checked and verified by the facility/
1.12.
operational manager or designated staff member
ON A WEEKLY BASIS
1.13. Complete and double check the weekly Reception/OPD/Emergency/WBOT Headcount summary
Enter the daily totals of the Headcount Register into the weekly Reception/OPD/Emergency/WBOT Headcount summary sheet. Add
1.14.
and double check the weekly Reception/OPD/Emergency/WBOT Headcount summary sheet
ON A MONTHLY BASIS
Enter the weekly totals of the weekly Reception/OPD/Emergency/WBOT Headcount Summary Sheet into the monthly Reception/
OPD/Emergency/WBOT Headcount summary sheet. Add and double check the monthly Reception/OPD/Emergency/WBOT Head-
count summary sheet and submit to the facility manager on the 1st day of each month
Filing should be done on the same day that input forms have been completed to avoid loss of information – file chronologically with
the latest documents at the top in a lever arch file
2.1.2 Health Care Provider Responsibilities

Health care providers (nurses, doctors and other health professionals) are responsible and accountable for ensuring
high quality data in individual patient files and on their own routine data collection and collation tools. These data
collection tools should be standardised registers.
It is essential that all health care providers write clearly and legibly on all data collection tools and limit the use of
abbreviations.
Data collection tools and processes for mobile clinics, outreach teams and other community based platforms, e.g.
school health services must be managed in the same manner as those for fixed facilities and submitted to the
manager of the ‘parent’ fixed facility to be captured into the routine health information system.
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2.1.2.1 Procedure: Health Care Provider

Step Action
ON A DAILY BASIS
RECORDING OF DATA ON DATA COLLECTION TOOLS
Record individual patient data in the facility retained patient file and if relevant, in the patient retained records (e.g. Antenatal cards
and Road to Health charts) during or directly after each patient contact. A copy of patient retained records must be retained in the
health facility
Capture the required data in eTick register or standardised paper register during or directly after each patient contact. Ensure that the
recording of data is in line with current standardised data element definitions
Indicate the patient file number clearly on the eTick register/paper register for patient follow- up and auditing purposes
Double check that all the correct data elements and the correct columns relating to health care interventions provided to patient were
ticked
Ensure that the register guidelines are followed during the recording of the patient encounters
Save the eTick register per the guidelines of the webDHIS system
Any data quality issues in the eTick register will be managed in line with the guidelines
Calculate, capture and sign daily totals clearly in standardised registers (electronic or paper) and submit for verification by facility
1.7.
manager
1.8. Submit checked and verified register to health information staff for capturing in webDHIS/eSummary sheets
ON A WEEKLY BASIS
1.
1.1. Complete and sign the weekly Tick Register summary form
1.9 File and store weekly Tick Register summary in a safe facility where access can be controlled
ON A MONTHLY BASIS
The manager/team leader of the service point (facility or non-facility based) or a designated person must add the totals for each data
1.10
element in the standard Tick Registers on the first day of each month to get a monthly total for the previous month
1.11 A line must be drawn after the totals for the month to indicate clearly when it was totalled
Copy the totals in the registers onto the Tick Register summary form to be submitted to the facility manager on the 1st day of each
1.12
month
2.1.3 Data Capturers Responsibilities

Data capturers, also referred to as data officers, are responsible for capturing data and then forwarding the data to the
next level.
Data capturers must spend 100% of their work time on the data-related responsibilities stipulated below.
2.1.3.1 Procedure: Data Capturer

Step Action
PHC FACILITIES
ON A DAILY BASIS
COLLATION OF DATA
Collect Reception Headcount register from reception
Check and verify the Reception Headcount register before capturing
Report problems found in the headcount register to the information manager/facility manager
Capture verified data for reception in webDHIS DDC if available – indicate capturing date and sign
Capture headcount data in HPRS and headcount register in the absence of health facility receptionist
Check for outliers, add comment. Mark record for follow up if applicable
Check for missing data, add comment and mark record for follow up
Run absolute validation checks
Follow up on incorrect daily data and provide feedback to clinicians to correct the eTick /paper tick register
Check that the incorrect record has been properly corrected
In line with the SOPs/guidelines for other systems (e.g. TIER.net or TB Register), collate and capture data as required
ON A WEEKLY BASIS
Monitor daily data entry for each service point
For eRegisters monitor that submissions were processed
ON A MONTHLY BASIS
Obtain validated data input forms from the facility manager on all monthly data sets on the 3rd day of each month if data is provided
on hard copies (paper based):
Conduct a rapid data quality assessment of data on data input forms – must be 100% complete and should contain no gaps or out-
liers without comments
Capture monthly data into the webDHIS
Indicate date of capturing on each monthly data input form and sign
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Check for outliers, add comment. Mark record for follow up if applicable
Check for missing data, add comment and mark record for follow up
Run absolute validation checks
Follow up on incorrect monthly data and do edits once the source documents have been corrected.
Mark record as completed after editing completed - by 5th of next month
File records and store safely in a facility with controlled access
In line with the SOPs/guidelines for other systems (e.g. TIER.net or TB Register), collate and capture data as required.
HOSPITALS
ON A DAILY BASIS
COLLATION OF DATA
Collect the signed midnight census report from the night supervisor and perform checks for completeness, correctness, consistency
and currency by checking the form and comparing with the midnight census data collection tools as well as other data collection tools
in the ward. Report any discrepancies found to the Operational manager for follow-up
Collect data collection tools (e.g. OPD tick registers, headcount registers, theatre and delivery registers) from service points/wards
Perform data quality checks on signed and verified data to ensure completeness, correctness, consistency and currency
Report any problems found
Capture data directly from the data collection tools into webDHIS (if doing daily data capturing to avoid collation of data
Run routine data quality checks in webDHIS that are appropriate for daily capturing
Follow up on incorrect daily data
File records and store safely in a facility with controlled access
Provide in house mentoring on completion of registers
ON MONTHLY BASIS
Collect data collation forms from wards/sections
Perform data quality checks on signed and verified data to ensure completeness, correctness, consistency and currency
Report any problems found
Capture data into webDHIS
Run webDHIS data quality checks
Follow up on incorrect data
File records needed to meet monitoring and audit requirements and store safely in a facility with controlled access
ON A QUARTERLY BASIS
1.17 Capture National Core Standards (NCS) data
ON AN ANNUAL BASIS
1.18 Capture Patient Experience of Care data
2.1.4 Health information officer responsibilities
Health Information officers should be progressively appointed at fixed facilities (clinics, community health centres and
hospitals). They are responsible for data quality assurance and encouraging local use of information.
If there are no data capturers at the facility the health information officer is responsible for the same procedures as
relevant for data capturers.
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Information officers/managers must spend 100% of their time on the data/information-related activities stipulated below.
2.1.4.1 Procedure: Health Information Officer
Step Action
MANAGEMENT AND SUPERVISION
Develop a health information plan specifying:
• Information needs of all stakeholders at service points
• Reporting processes
• Areas for improvement
Provide staff who collect data with training on data elements to be collected and tools to be used to collect data as well on how to
analyse their own data
Keep submission logs for monitoring adherence to reporting timeframes and identification of bottlenecks for remedial action
Ensure that all documents required for monitoring and auditing are filed correctly and stored in a facility with controlled access
PRIMARY HEALTH CARE FACILITIES
ON A DAILY BASIS
2 DATA MANAGEMENT
If the facility has a Local Area Network (LAN) set up between reception/facility manager computer and consulting room computers
2.1
check the main server computer daily to ensure that backups from each consulting room have been saved to the server computer
If eTick register is used ensure that there is a register saved for each consulting room in the health facility to ensure that all clinicians
2.2
submitted their daily register. Report to the facility manager if any consulting room register is missing for the day
Copy all backed up registers from the server computer onto a removable drive and ensure that it is locked up in a safe location in
2.3
the health facility (preferably a safe)
2.4 Ensure that these backups remain properly saved in folders which can be retrieved for auditing purposes
2.5 Monitor that daily data capture for reception/service points has been done
Check that all service points’ eTick Registers have uploaded to webDHIS/summaries have been received
• Run validation checks on service points
2.6
• Check for outliers and missing data
• Mark records for follow up where appropriate
2.7 Draw a follow up report from webDHIS and give to facility manager
Ensure that the corrections received from the facility manager are captured and that there is a clear audit trail back to the source
2.8
documents
2.9 Check that corrections to the eTick Registers have uploaded to webDHIS
Monitor that daily data capture has been done on eSummary sheet and that there is no backlog in capturing eSummary sheets from
2.10
all service points
ON A MONTHLY BASIS
2.11 Monitor that monthly data capture has been done
2.12 Check that all data from outreach teams has been captured if relevant
2.13 Draw follow up reports from webDHIS and ensure that all the edits are done timeously
2.14 Do validation checks and ensure that edits are done timeously
2.15 Conduct pre-submission data validation on a monthly basis with facility staff and draft feedback report
2.16 Discuss persistent data quality problems found in source documents with facility manager
Develop webDHIS customised pivot table, GIS and data visualizer favourites, customised dashboards for use in reports and facility
2.17
data analysis
2.18 Compile a monthly information report for the facility
2.19 Provide customised reports to line/programme managers
2.20 Present information report at facility meetings
2.21 Provide information for facility review meetings
2.22 Attend sub-district meetings as required and report on facility information
2.23 Submit ART quarterly data (zipped xml format) into webDHIS
ON AN AD HOC BASIS
3 DATABASE MANAGEMENT AND TRAINING
3.1 Ensure that all hardware and software is fully operational and report IT related problems to sub-district IT
Run troubleshooting procedures as relevant to different information systems;
3.2 • Data bundles (if not uncapped)

• Connectivity
• DHMIS help desk
Ensure that zipped eTick register and all monthly data input forms are sent to the lowest level that is online - hospital/sub-district or
3.3.
district for importing into webDHIS
3.4 Obtain report of analysed data with appropriate pivot tables and charts from sub-district/district and use to generate facility feedback
3.5 Provide training to clinicians on use and maintenance of electronic registers
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Assess training needs, provide and coordinate training for hospital staff on information related topics including the use of dashboards,
3.6
pivots, charts, maps for reporting
3.7 Contribute to orientation of all new staff on health information management system
Contribute to training on data elements, data quality assessment and data use for all staff responsible for data collection and collation
3.8
and managing service points/wards
3.9 Guides with audit readiness activities
ON A QUARTERLY BASIS THE INFORMATION OFFICER IS ACCOUNTABLE FOR THE FOLLOWING:
Receive ART quarterly TIER.net export (zipped xml format) from data capturer
Submit TIER.net export (zipped xml format) to the lowest level that is online – hospital/sub-district or district for importing into
webDHIS
HOSPITALS
ON A DAILY BASIS
1 DATA MANAGEMENT
Monitor that daily data capture for wards/sections has been done if data is captured daily/summaries of paper based registers ob-
tained
Draw a follow up report from webDHIS and give to operational managers
ON A MONTHLY BASIS
1.3. Monitor that monthly data capture has been done
Draw follow up reports from webDHIS and ensure that all the edits are done timeously
Do validation checks and ensure that edits are done timeously. Ensure that the perinatal and child deaths data to be captured on
DHIS is checked against the PPIP and CHIP data.
Conduct pre-submission data validation monthly with hospital staff and draft feedback report
Develop and maintain customised pivot table, GIS and data visualizer favourites for the hospital
Develop and maintain customised dashboards for use in reports
Use the public dashboards and favourites as templates for hospital data analysis
Compile a monthly information report for the hospital
Provide customised reports to line/programme managers
Present information report at hospital meetings and discuss persistent data quality problems found in source documents with hospital
managers
Provide information for hospital information review meetings
1.15. Supervise the capturing of National Core Standards and reporting
ON AN ANNUAL BASIS
1.16. Supervise the periodic capturing of the Patient Experience of Care and reporting and analysis of findings
ON AN AD HOC BASIS
2 DATABASE MANAGEMENT AND TRAINING
Assess training needs, provide and coordinate training for hospital staff on information related topics including the use of dashboards,
2.1.
pivots, charts, maps for reporting
2.2 Contribute to orientation of all new staff on health information management system
Contribute to training on data elements, data quality assessment and data use for all staff responsible for data collection and collation
2.3
and managing service points/wards
2.4 Guide audit readiness activities
2.5 Ensure that all hardware and software is fully operational and report IT related problems to hospital/ sub-district IT
2.1.5 Facility Manager’s responsibilities

The provider-patient interaction at the health facility is the foundation for effective and efficient routine health information
management. If health facility data submitted for capturing into the RHIS is of poor quality, evidence-based management
decisions are compromised at all levels.
The health information management, monitoring and reporting responsibilities of health facility managers are similar at
all types of facilities and these focus on the management of high quality information that must be used to:
• optimise patient/client care

• optimise public health and the health status of the population
• optimise performance of health programs and the healthcare system
• improve data quality
• monitor, evaluate and report on performance against all legislated plans in the health sector
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With regards to filing, archiving and disposal of patient records and registers, the facility manager must:
• Ensure that a health record is created and maintained at the facility for every user of the health service.
• Set up control measures to prevent unauthorised access to those patient records and registers and to the storage
facility in which, or system by which, records and registers are kept.
• Take responsibility for the management of the patient records of the facility.
• Assign administrative staff to manage patient records at reception and filing.
2.1.5.1 Procedure: Facility Manager

Step Action
All facilities
INFORMATION MANAGEMENT
Provide sufficient resources for routine health information management
Mobilise for further resources (staff, data collection tools, hardware and software, email and internet connections) per national
guidelines
Include data management, monitoring and reporting in performance contracts and job descriptions of all managers
Ensure training on data elements, data quality assessment and data use for all staff responsible for data collection and collation and
managing service points
Ensure that all new staff are orientated on health information management system in the facility.
Compile a patient and data flow plan for the facility indicating where patient is received and headcounts are done and where service
points are
Ensure that staff concerned know how to use the eTick register
Conduct weekly spot checks – correlation of registers with what has been captured in systems, filing practices for data verification
and audits.
Conduct internal audits, data quality assessments and patient file reviews
Keep dated and signed records of spot checks
Verify all monthly data before it is captured in webDHIS
Follow up on feedback from the health information officer/data capturer and ensure that clinicians correct the eTick Registers.
Ensure that updated data quality reports and pivot table of raw data are received from the health information officer/data capturer
after corrections were made in the DHIS
Oversee, lead and support effective and efficient data collection, management and use on:
•Patient visits and care/interventions provided
•Clinical work days and supervision visits
•Stock and equipment
Sign off eSummary Registers and send to next level for importing into webDHIS
Ensure that data and information are part of the standing item in the management agenda of a facility and promote an information
culture.
Follow up on feedback from the health information officer/data capturer and make corrections. Draw a line through the incorrect
value in the source document, write in the new value. These changes are to be initialled and dated. No correction fluid is to be used.
Approve/sign off data after verification. This process must be finalised by the 5th of the month following the reporting period.
Ensure that the validation rules that were violated are corrected or commented on and that feedback on violations are given to the
sub-district/sub-structure/district office if these were only corrected after 5th of the next month
Ensure that outliers are commented on
Attend sub-district and district meetings as required and report on hospital information
Ensure that the facility is ready for audit at any time
2 PROVIDE FEEDBACK
1.
2.
2.1 Data quality – timeliness, completeness and accuracy of data
2.2 Program-related indicators highlighting good performance and service delivery shortcomings
2.3 Develop action plans with facility staff for indicators showing poor performance
Follow up on feedback from the health information officer/data capturer and make corrections. Draw a line through the incorrect
2.4
value in the source document, write in the new value. These changes are to be initialled and dated. No correction fluid is to be used.
Ensure that the validation rules that were violated are corrected or commented on and that feedback on violations is given to the
2.5
sub-district/sub-structure/district office
2.6
Monthly approval and sign off data:
2.7 Sign off monthly summary report and supervise submission to next level for capturing in webDHIS if not capturing in facility
Ensure that the eTick register data is zipped and that it is sent to the lowest level with connectivity for importing into webDHIS
2.8 Ensure that the facility receives feedback from the sub-district/district on data submitted in the form of reports/pivot tables/charts
16
2.9 Verify all data before it is sent to the next level for capturing/importing
Monthly approval and sign off data:
2.10 Sign off monthly summary report and supervise submission to next level for capturing in webDHIS.
2.11 Ensure that the facility receives feedback from the sub-district/district on data submitted in the form of reports
Follow up on feedback from the sub-district and make corrections. Draw a line through the incorrect value in the source document,
2.12 write in the new value. These changes are to be initialled and dated. No correction fluid is to be used. Ensure that the eSummary
Register is corrected, zipped and saved to memory stick and submitted to next level for importing into webDHIS
Ensure that the validation rules that were violated are corrected or commented on and that feedback on violations is given to the
2.13
sub-district/district office
WBOT and School health (If applicable) services
Weekly spot checks –OHH records/client clinical record reviews, filing practices for data verification and audits.
Keep dated and signed records of spot checks
Verify data in registers /daily collection tools weekly and sign off
Verify monthly data in source documents and sign off
Collate and submit data to nearest facility/district/sub-district with connectivity/sub-district/district for capturing in webDHIS
Ensure that data quality report and pivot table of raw data is received from sub-district/district
Ensure that valid outliers are commented on and that incorrect outliers are fixed
Ensure that updated data quality reports and pivot table of raw data are received from the sub-district after corrections were made
in the webDHIS
AUDIT READINESS
A facility is ready for an audit when:
• All internal policies and procedures documents are available and are implemented
• All staff are trained on all policies and procedures and there is evidence of this training
• Each patient has only one patient folder/clinical record and file is and is always available in the facility (proper
filing system)
• Information recorded on data collection tool (Tick Register, standard register or patient based software
application) are consistent with patient folder and supporting documentation
• Where applicable all patient records are captured on electronic databases, e.g.ETR.net, TIER.net, webDHIS
• Information recorded in DHIS is consistent with data input forms
• All data input forms applicable to the facility have data collected for and are captured in the DHIS
• All data collection tools used for collection of data by institution have been reviewed for quality and have been
signed off by the health care provider who collected the data
• All registers must be reviewed for quality and have been signed off by the facility manager
• All validation errors are corrected or explained
• All outliers are explained
• Processing of data updates is done correctly
• Sign off forms are properly completed and signed off by the facility manager
17
3. Reference Documents
Individuals using these procedures should become familiar with the following documents:
3.1 DHMIS Policy, National Department of Health, 2011.

3.2 Ideal Clinic Manual (October 2015)
3.3 National Health Act (Act 61 of 2003): Commencement Section 53 of the National Health Act, 2003.
3.4 National Archives of South Africa Act (No. 43 of 1996).
3.5 Promotion of Access to Information Act (Act 2 of 2000): GN 585, Government Gazette 26332, 14 May 2004.
3.6 Public Audit Act of 2004 (Act 25 of 2004): Government Gazette Vol 474, Cape Town, 20 December 2004 No.
27121.
3.7 Public Finance Management Act (Act 1 of 1999): Public Finance Management Amendment Act (Act No. 29 of
1999).
3.8 Statistics Act (Act 6 of 1999): Government Gazette Vol. 406, Cape Town 21 April 1999. No. 19957.
3.9 Treasury Regulations: Government Gazette, Vol. 500, Pretoria, 20 February 2008, No. 29644.
18
4. ANNEXURES
All facilities should use the rationalised data collection tools as specified in the current National Indicator Data Set
(NIDS).
4.1 List of registers/data collection tools
4.1.1 PHC facilities

PHC Comprehensive Register and Headcount Register
Workday equivalent spread sheet for workdays data
4.1.2 Hospitals
Hospital Tick Register OPD and Headcount Register
Casualty Register
Midnight census
Theatre Register
Delivery Register
Ward register
4.1.3 PHC facilities and hospitals

Complaints register
Patient safety incident register
TB Register and TB identification (suspect) register
ART Data Collection Tools
HIV Testing and Counselling
4.1.4 Ward based PHC outreach (WBPHCOT) teams

Household Registration Form
CHW Household Visit Tick sheet
CHW Visit Monthly Summary
Individual Adult Health Record
Maternal Child Health Record
OT Monthly Summary Form
Referral Back Referral Form
4.1.5 School Health
Parent Information Leaflet for ISHP Learner Assessment SHS 1a

Learner Information Leaflet for ISHP Learner Assessment SHS 1b
Consent Form for ISHP Learner Assessment SHS 1c
Assent Form for ISHP Learner Assessment SHS 1d
ISHP Learner Assessment Form: Foundation and Intermediate SHS 2a
ISHP Learner Assessment Form: Senior and FET SHS 2b
ISHP: Letter to parent /guardian regarding need for referral/follow-up SHS 3
ISHP: Referral letter SHS 4
ISHP Follow-up Assessment Form SHS 5
ISHP Health Education Data Collection Tools SHS 6
ISHP Daily Register SHS 7
Record of Learners referred for further assessment SHS 8
ISHP Summary Report: School SHS 9
ISHP Summary Report: Sub-district, District, Province SHS 10
4.1.5 Sexually transmitted infection (STI) sentinel sites:

STI Sentinel site tally sheet (additional to other PHC registers)
19
4.2 Guidelines to completing registers
4.2.1 PHC Reception Headcount Register

• Must be placed at the reception area and used by the staff member that is at the reception area for the day. It
should be placed at each point where there is more than 1 reception area
• It manually registers a patient/client whenever he/she enters the facility
• It is used to provide an accurate headcount for the number of patient/clients that enter a facility for a service
daily
• Essentially, it generates one patient/client as one headcount daily. Therefore, this register is used as a tool to
validate the headcount monthly.
4.2.2 Comprehensive Tick Register and forms for PHC facilities, hospitals, WBOT and School health services
• The Tick register include all data elements required for routine reporting.
• The purpose of this register is to collect routine information about patient per the reporting requirements from
National and Provincial Department of Health.
• This register should be available at every consulting room/service point where patients are seen both by
the health service provider. Information about the patient should be entered when the patient arrives for a
consultation.
• A register is allocated to a consulting room/service and not to a health service provider. The register must
remain in that consulting room.
• The tick register consists of a space for a patient file number to link patient file for supporting high quality
integrated comprehensive care, follow-up, data verification and auditing.
• Start a new day on a new page irrespective of whether the register is not filled.
• This is required for validation purposes as the health service provider that occupies a consulting room will sign
at the end of each day.
• Do not add any columns on the register to capture other data elements.
• Do not modify the headings on the register.
• Do not write or make notes on the register, except for a tick in the appropriate column.
• Once register is completely full, follow the records management and archive processes.
Steps: Comprehensive Tick Register

Step 1 Record facility name, month and consulting room number/service (the number on door of consulting room)
Step 2 Record the date (DD/MM/YY for example: 20/11/15)
Step 3 Record patient file number – this may be generated by HPRS/hospital system/manual numbering system
Step 4 Record patient/client name
Step 5 Use a tick (not a cross) to indicate the service that the patient was provided with
Step 6 At the end of the day, count the number of ticks under each data element. This will inform the total number of patient/clients
for the day
Step 7 Fill in running totals. (see example below)
Step 8 The staff member who summarised the register for a specific consultation room will write out name in full and sign
Step 9 Monthly, the team leader, OM or PHC supervisor will review the data and will note their name and the date and sign on the
register
The reviewer will review the following:

• All the fields have been completed
• The number of ticks correspond to the totals
• It has been signed by the staff member who has totalled the register at the end of the day for that specific
consulting room
Running Totals
The purpose of the running total is to provide a total number of patient/clients seen per programme at the end of every
month
On a new day, the previous day’s totals per element are carried over as the next day’s running total
The running total is then added to all patient/clients seen per data element
The Running Total + the Number of patient/clients seen for the day = TOTAL per day
For example:
Day 1: BCG dose (usually at birth): 5 patient/clients are seen for the day
Day 2: 5 patient/clients are recorded under the BCG dose (usually at birth) as a running total. On day 2 if 6 patient/
clients were seen, at the end of the day the TOTAL will be 11 (5+6=11)
Day 3: 11 patient/clients are recorded under BCG dose (usually at birth) as the running total. On day 3 if 4 patient/clients
were seen, the total will be 15 (11+4=15)
20
4.3 Weekly Tally Summary and Monthly Tally Notepad

• The weekly tally summary and monthly tally notepad are tools used for the collation of data and subsequent
reporting at the end of the month.
• For those facilities that have Daily Data Capturing (DDC), data will be captured daily thereafter used for monthly
reporting.
• For those facilities that do not have DDC, data is captured manually on the weekly tally summary and thereafter
used for monthly reporting.
• Data Input forms should be verified and signed by the facility manager on a weekly and monthly basis before
being captured on DHIS.
4.3.1 Weekly Tally Summary
• The Weekly Tally Summary Book is used to collate all totals in the facility for each element.
• It collects information for a week that runs from Monday – Sunday.
• The weekly tally summary sheet must be completed from the 1st day of the month to the last day of the month
(i.e. 1st – 30th or 31st)
• Each weekly tally summary is separated into 13 months (an extra month is provided)
• Every morning or evening the data clerk/capturer must collect the totals for all elements from all registers in the
consultation rooms.
• Totals are added together to give a daily total.
• Using OPV 1st dose under 1 year (6 weeks) as an example on 1 February 2015:
o Room 1 total: 10, room 2 total: 5, room 3 total: 8, room 4 total: 10, therefore the daily total for this
element is 33.
• At the end of every week, the daily totals for all elements must be added to give a weekly total.
• Weekly totals are transferred to the weekly sheet, this information is collated to give monthly totals which will
then be recorded on the monthly notepad
• This form must be completed by data clerk/data capture or any other staff member responsible for data collation.
• The data capture completes collects and collates the data
• The Operational Manager conducts the data quality check
• If service is not rendered by the facility, add ‘N’ next to element
• If service was rendered and no patient/clients were seen add a ‘0’
Steps to complete Weekly Tally Summary
Step 1 Fill in facility name and date

Step 2 Fill in the month and year
Step 3 The data capturer/s must fill in their name and contact number
Step 4 Under each day of the week add the date
Step 5 For each day of the week, record totals for each data element
Step 6 At the end of week, the totals will be added
Step 7 A data quality check should be conducted by the operational manager
Step 8 All fields should be checked if completed and the reasons for incompletion
Step 9 The operational manager or PHC supervisor will sign and insert date at the end of each week
and quality check
21
4.4 Data Quality Checklist: FACILITY MANAGER CHECKLIST: PRE-SUBMISSION DATA VALIDATION
This checklist is primarily for monthly checks but can be used on weekly, monthly or quarterly basis according to
needs. Please tick off in check box next to task completed
 Weekly spot checks done on patient clinical records (at least 10 records per month) to assess accuracy of recording
 Data collection tools checked:
· Numbered correctly
· Completed correctly and legible
· Calculations done correctly
· Signed off by data collector and dated
· Registers have lines drawn, totalled and signed and dated by designated person for the relevant reporting period
 Data discussed and approved by facility information team
 Data Summary Forms received from all required components of service
 Data Summary Forms received within prescribed timeframes
 Late submissions of Data Summary Forms addressed (if applicable)
 Data quality reports and pivot table of raw data reviewed of data captured in DHIS at end of reporting period
 Data compared with previous 11 months’ data
 Data checked for data quality errors:
· consistency (with patient folders, data collection tools, previous data and other relevant data elements)
· completeness
· correctness
· gaps or blanks
· calculation errors
· capturing in wrong fields
 All outliers checked and commented on
 All validation errors corrected or explained
 All discrepancies in data addressed and resolved with data collector
 Any changes to Data Summary Forms made in writing, initialled, dated and returned to collection point
 Completed Data Input Form signed off by the data capturer/health information officer and the facility manager
 Corrected signed-off Data Input Form submitted for capturing on DHIS
 Updated quality reports and pivot table of raw data received after corrections made in DHIS
 Data captured in DHIS is consistent with Data Input Form
 Data collection tools, Data Summary Forms and Data Input Forms filed safely and correctly
22
4.5 Facility Data Sign-off form
FACILITY DATA SIGN OFF FORM

This form is to be completed by the facility manager and submitted to the Sub District/Sub Structure Office by the 7th of the month.
Facility Name: _____________________ Facility Manager Name: ___________________

Period (month\year): ________________ Contact Number: ______________________________
Data quality check to be performed
Mark with a where applicable
Outliers
All Forms All Elements Corrected or Validations
Datasets Comments
Received Completed Commented Corrected
on
Y N N/A Y N Y N Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Y N N/A Y N
Facility Manager: __________________________ ________

Signature Date
Sub-district/Sub-structure IO: _____________ _____ Facility IO/DC: _________________ ____

Signature Date Signature Date
23
NOTES
24
25
National Department of Health
Civitas Building
Cnr Thabo Sehume and Struben Streets
Pretoria
0001
Switchboard: 012 395 8000
www.health.gov.za
26

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Standard Operating Procedure for District Health Management Information System (DHMIS): Facility level

Standard Operating Procedures Facility Level Updated Edition December 2016

DISTRICT HEALTH MANAGEMENT INFORMATION SYSTEM (DHMIS)

Standard Operating Procedures

FOREWORD BY THE DIRECTOR-GENERAL

In July 2011, I approved the District Health Management Information

ART Antiretroviral Therapy

TERMINOLOGY OPERATIONAL DEFINITION

2.1.1.1 Procedure: Health Facility Receptionist/Patient Registration Staff

2.1.2 Health Care Provider Responsibilities

2.1.2.1 Procedure: Health Care Provider

2.1.3 Data Capturers Responsibilities

2.1.3.1 Procedure: Data Capturer

1.17 Capture National Core Standards (NCS) data

2.1.4 Health information officer responsibilities

3.2 • Data bundles (if not uncapped)

2.1.5 Facility Manager’s responsibilities

• optimise patient/client care

2.1.5.1 Procedure: Facility Manager

3.1 DHMIS Policy, National Department of Health, 2011.

4.1 List of registers/data collection tools

4.1.1 PHC facilities

4.1.3 PHC facilities and hospitals

4.1.4 Ward based PHC outreach (WBPHCOT) teams

4.1.5 School Health

Parent Information Leaflet for ISHP Learner Assessment SHS 1a

4.1.5 Sexually transmitted infection (STI) sentinel sites:

4.2 Guidelines to completing registers

4.2.1 PHC Reception Headcount Register

Steps: Comprehensive Tick Register

The reviewer will review the following:

4.3 Weekly Tally Summary and Monthly Tally Notepad

4.3.1 Weekly Tally Summary

Step 1 Fill in facility name and date

4.5 Facility Data Sign-off form

FACILITY DATA SIGN OFF FORM

Facility Name: _____________________ Facility Manager Name: ___________________

Facility Manager: __________________________ ________

Sub-district/Sub-structure IO: _____________ _____ Facility IO/DC: _________________ ____

National Department of Health

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Facility Name: ___ Facility Manager Name: _

Facility Manager: __________________

Sub-district/Sub-structure IO: ___________ _ Facility IO/DC: ___________