7. Documentation and Reporting

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Clear and accurate documentation of all aspects of the patient’s care is critical to ensure safety, quality and continuity of care. It facilitates assessment, diagnosis, planning, implementation and evaluation of patient care.

Documentation is also a tool for accountability purposes and provides data to protect the interests of the patient, health facility and health professionals and is essential to risk management.

a. Responsible persons:

  • Superintendent/Civil Surgeon/UHFPO/Senior Consultant of the Sadar/Upazila Hospital and In charge of the IDU at other hospitals

Upazila Rabies Prevention and Control Centre: Manual Data entry using register and monthly reporting dog bite cases.

District Rabies Prevention and Control Centre: Manual Data entry using register and send to DHIS2 and email to CDC report rabies case.

National Rabies Prevention and Control Centre, IDH, Dhaka: Manual Data entry using register and monthly reporting dog bite and rabies cases.

Rabies Prevention and Control Centre, BITID, Chattogram: Manual Data entry using register and monthly reporting dog bite and rabies cases.

Fig. 12: Case reporting bottom to top approach

b. Documentation:

To be ensured at different levels of the District and Upazila as follows:

  • At Emergency:

Use a Registrar book and/ or digital recording in a computer with following information: Emergency ID no./ Date of seeking care/ Name of the patient/ Age/ Sex/ Address/ Major clinical presentations/ OE findings/ Provisional diagnosis/ Management of the case.

  • At OPD: Use a Registrar book and/or digital recording in a computer with following information: Emergency/ OPD ID no./ Indoor ID no./ Date of admission/ Name of the patient/ Age/ Sex/ Address/ Major clinical presentations/ OE findings/ Provisional diagnosis/ Investigations/ Management of the case.

c. Reporting:

  • Reports should be prepared at regular intervals for central authorities/ MIS/ CDC/ IEDCR, because these are used for policy making and implementations (Annex 3 and 4).
  • Different types of reports should be prepared: Disease Profile (listing all diseases managed in a specified period of time).

Fig. 13: Impact of national rabies elimination activities on human rabies incidence in Bangladesh 2012–2021