Notifiable Medical Conditions Case Notification Form Completion Guide

 

Note: Where faint grey italicised text is given in the response boxes, the response must be written on top of the grey font. This font is meant to inform the notifier as to what information goes into that respective box.

 

SECTION 1 – NOTIFYING HEALTH FACILITY DETAILS

All information collected under this section relates to the health facility reporting the diagnosed NMC.

 

HEALTH FACILITY NAME


 

Description: This filed identifies the health facility as it is reflected on the DHIS org unit hierarchy where the NMC is being reported/notified.

Instructions: Enter the name of the health facility as it is reflected on the DHIS org unit hierarchy. Put Provincial prefix in lower cases i.e. kzn HEALTH_FACILITY_NAME.

 

 

HEALTH FACILITY CONTACT NUMBER


 

Description: This field identifies the telephone number of the health facility that is reporting/notifying the diagnosed NMC.

Instruction: Enter the telephone number of the health facility in the space provided.

 

 

HEALTH SUB-DISTRICT


 

Description: This filed identifies the health Sub-District of the health facility that is reporting/notifying the diagnosed NMC.

Instructions: Enter the name of the health Sub-District as it is reflected on the DHIS org unit hierarchy.

 

 

PATIENT FILE/FOLDER NUMBER


 

Description: This field identifies the health facility patient file number.

Instructions: Enter the health facility patient file number in the space provided.

 

 

PATIENT HPRS-PRN


 

Description: This field identifies the Health Patient Registration System – Patient Registration Number.

Instructions: Enter the HPRS-PRN in the space provided. If the facility is not yet on the HPRS-PRN, leave this field blank.

 

DATE OF NOTIFICATION


 

Description: This field identifies the date the NMC is reported/notified by the nurse or doctor within the health facility to the next level. The date format must be yyyy-mm-dd.

Instructions: Enter the date in the space provided.

 

 

SECTION 2 – PATIENT DEMOGRAPHICS

All information collected under this section relates to the patient who has been diagnosed with a NMC.

 

 

FIRST NAME AND SURNAME


 

Description: This field identifies the first name and surname of the patient as it appears on their identity document.

Instructions: Enter the first and last name of the patient in the space provided.

 

 

SA ID NUMBER


 

Description: This field identifies the 13 digit South African identity number of the patient.

Instructions: Complete the 13 digit South African identity number of the patient in the space provided.

 

All South African citizens are encouraged to provide the SA identity number that can be used as unique identifier to link all patients’ health information including laboratory tests.

 

PASSPORT OR OTHER ID NUMBER


 

Description

Passport number:  This field identifies the patient’s passport number. Must only be completed if the SA ID number is not available.

Other ID number: This field identifies an identity number other than the SA identity number or the passport number of the patient. Numbers that must be captured under this field include but are not limited to asylum numbers, drivers licence numbers, non-South African national ID numbers.

Instructions: Complete the passport or other identity number of the patient in the space provided.

 

 

CITIZENSHIP


 

Description: This field identifies the patient’s nationality or country of origin.

Instructions: Enter the patient’s citizenship in the space provided.

 

 

DATE OF BIRTH


 

Description: This field identifies the date the patient was born.

Instructions:

  • Enter the date of birth in the space provided. The date format must be yyyy-mm-dd.
  • If ONLY the year of birth is known, but not the month and day, enter the last day of the month of June, i.e., YYYY/06/15.
  • If ONLY                 the year and month of birth are known, but not the day, enter the day as the last day of the month, i.e., YYYY/MM/15.

 

AGE


 

Description: This field identifies the age of the patient.

Instructions:

  • Enter the age of the patient in the Years box if the patient is aged 1 year and above.
  • Enter the age in months in the Months box if the patient is less than one year but over one month.
  • Enter the age in days in the Days box if the patient is aged less than one month.

 

 

GENDER


 

Description: This field identifies the biological sex of the patient.

Instructions: Mark appropriate gender box with an X.

 

 

IS PATIENT PREGNANT


 

Description: This field identifies whether the patient is pregnant at the time of diagnosis.

Instructions: Place an ‘X’ in the appropriate box.

CONTACT NUMBER


 

Description: This field identifies telephone or mobile number of the patient.

Instructions: Enter the contact number in the space provided.

 

 

RESIDENTIAL ADDRESS


 

Description: This field refers to the street address, village, town or city where the patient physically resided at the time the diagnosis was made.

Instructions:

  • 1st line – only enter the street/ dwelling unit number
  • 2nd line – only enter street name
  • 3rd line – only enter location/village/suburb
  • 4th line – only enter town/city and postal code
  • Provide the land description if the street or mailing address is unavailable.
  • If the patient is considered homeless, indicate “no fixed address” in the street address

 

 

EMPLOYER/EDUCATIONAL INSTITUTION ADDRESS


 

Description: This field is meant to document place where the patient spends most of their time other than their residential dwelling place. For employed adults this refers to their place of work. For minors who are enrolled in school, this refers to their school address.

Instructions:

  • 1st line – only enter the name of the institution
  • 2nd line – only enter the street/dwelling number and name
  • 3rd line – only enter the location/village/suburb
  • 4th line – only enter town/city and postal code
  • If the street address is not known then use the postal address (including postal box number).

 

EMPLOYER/EDUCATIONAL INSTITUTION CONTACT NUMBER

 

Description: This field identifies the telephone number of the employer/educational institution of the patient.

Instructions: Enter the contact number in the space provided.

 

SECTION 3 – MEDICAL CONDITIONS DETAILS

This section documents details of the medical condition being notified.

A list of all medical conditions that are notifiable is provided on the front page of the notification booklet and is also appended here.

 

NMC DIAGNOSED


 

Description: This field identifies the name of the medical condition notifiable by Section 90 (1) (j), (k) and (w) of National Health Act, 2003 (Act no. 61 of 2003)}

Instructions:

  • Enter the name of the clinically suspected or laboratory confirmed notifiable medical condition that is being notified/reported.
  • If a patient is diagnosed with more than one NMC, complete and submit a separate NMC case notification form.

 

You must NOT wait for a laboratory confirmation to notify category 1 NMC.

 

 

HISTORY OF POSSIBLE EXPOSURE TO NMC IN THE LAST 60DAYS


 

Description: This field identifies risk of exposure due to the patient having been in contact with a person who had or was suspected to have had the same NMC as the one being reported.

Instructions: Place an ‘X’ in the appropriate box.

 

 

METHOD OF DIAGNOSIS


 

Description: This field identifies the method of diagnosis for the NMC being reported.  Methods of diagnosis include but are not limited to rapid tests, laboratory diagnosis, clinical signs and symptoms only, biopsy and X-rays.

Instructions:

  • Indicate how the diagnosis was made by selecting one or more from the options provided (mark with X).
  • If other is marked, then specify what diagnostic method was used. These may include scans, biopsies etc.

 

 

 

 

 

CLINICAL SYMPTOMS RELATING TO THE NMC


 

Description: This field indicates the classical clinical symptoms that the patient presents with at time of diagnosing the NMC, i.e. symptoms used to come up with the diagnosis.

Instructions: List two or more presenting symptoms for the diagnosed NMC in the space provided.

 

 

TREATMENT GIVEN FOR THE NMC


 

Description: This field indicates medication given to treat the NMC being notified.

Instructions:  List medication given to the patient to treat the diagnosed NMC.

 

Only document treatment specific for the NMC excluding non-specific treatment such as pain relievers (paracetamol etc).

 

 

DATE OF DIAGNOSIS 

 

Description: This field indicates the date the NMC was diagnosed. For NMC initially diagnosed via laboratory tests i.e. majority of category 2 and category 3 NMC, the date of diagnosis will be the date of laboratory results.

Instructions: Enter the date in the space provided. The date format must be yyyy-mm-dd.

 

 

DATE OF SYMPTOM ONSET


 

Description: This field indicates the date the patient first noticed signs and symptoms of the NMC being reported.

Instructions:

  • Enter the onset date in the space provided. The date format must be yyyy-mm-dd.
  • If the exact date of onset is unknown, ask the patient to give an estimate date.
  • In the case of death notifications or comatose patients date of symptom onset should be marked as unknown.

 

 

 

 

PATIENT ADMISSION STATUS

 

Description: This field identifies whether the patient is an inpatient/outpatient or discharged at the time of notification.

Instructions: Select from the options provided and if patient is admitted, enter the ward name in the space provided.

 

 

PATIENT VITAL STATUS


 

Description: This field identifies whether the case is alive or deceased at the time of diagnosis.

Instructions: Place an ‘X’ in the appropriate box.

 

 

DATE OF DEATH


 

Description: This field identifies the date of death of the case

Instructions:

  • Enter the date of death of the case in the space provided. The date format must be yyyy-mm-dd.
  • If ONLY the year and month of birth are known, but not the day, enter the day as the last day of the month, i.e., YYYY/MM/15

 

 

 

SECTION 4 – TRAVEL HISTORY IN THE LAST 60 DAYS

This section captures any travel that the patient might have done in the last 60 days prior to date of NMC diagnosis

 

DID THE PATIENT TRAVEL OUTSIDE OF USUAL PLACE OF RESIDENCE?


 

Description: This field identifies whether the patient travelled outside of their normal place of residence in the last 60 days prior to date of diagnosis. Travel outside applies to travel to a different area in-terms of town, district, province or country.

Instructions:

  • Place an ‘X’ in the appropriate box.
  • If No: Proceed to next section (Specimen Details).
  • If Yes: List the province(s)/ country(ies) visited in the last 60 days and where possible the town(s)/city(ies) visited in that province/country.
  • Enter the departure and return dates in the space provided. The date format must be yyyy-mm-dd.

 

Departure date is date when patient left usual place of residence and return date is date when patient left the place of visitation.

 

SECTION 5 – VACCINATION HISTORY FOR THE NMC DIAGNOSED

This section pertains to vaccine preventable diseases only. It captures details relating to vaccines given for the NMC being reported

 


 

Description: This field documents whether the patient has received timely and adequate vaccination against the NMC that they are presenting with according to the Department of Health recommended vaccination dosing schedule.

Instructions: Place an ‘X’ in the appropriate box. Select only one.

 

Definitions:

Not vaccinated The patient has received no vaccination for the vaccine preventable NMC being reported.
Up-to-date The patient received vaccination for the vaccine preventable NMC being reported and is considered fully vaccinated for that disease.
Unknown It is not known if any vaccination has been received for the vaccine preventable NMC being reported or unable to find vaccination history of the case.

 

 

 

SECTION 6 – SPECIMEN DETAILS


 

This section documents details related to the specimens that were collected to assist in confirmation of the clinically suspected NMC

 

WAS A SPECIMEN COLLECTED?


 

Description: This field confirms whether or not specimen(s) were collected for confirming the clinically suspected NMC.

Instructions: Place an ‘X’ in the appropriate box.

 

 

DATE OF SPECIMEN COLLECTION


 

Description: This field documents the specimen date i.e. the date the specimen was obtained or drawn from the case.

Instructions:  Enter the date the specimen was drawn from the patient in the space provided.  The date format must be yyyy-mm-dd.

 

 

SPECIMEN BARCODE


 

Description: This field uniquely identifies the specimen. For NHLS specimens, this refers to the NHLS pre-printed specimen barcodes that are provided with the specimen request form.

Instructions:

  • Stick the laboratory barcode sticker on the space provided.

 

Only in cases where the physical barcode sticker is unavailable should the barcode be handwritten so as to reduce barcode errors.

 

 

SECTION 7- NOTIFYING HEALTHCARE PROVIDERS DETAILS

This section documents the details of the health care provider who diagnosed the case.

 

FIRST NAME AND SURNAME


 

Description: This field identifies the first name and surname of the notifying health care provider as it appears their identity document.

Instructions: Enter the first and last name of the notifying healthcare provider in the space provided.

 

 

SANC/HPCSA NUMBR


 

Description: This field identifies the notifying health care provider’s health profession council registration number.

Instructions:

  • Enter the notifier’s South African Nursing Council or Health Professions Council of South Africa number.

 

 

MOBILE NUMBER


Description: This field identifies the mobile number of the notifying healthcare provider.

Instruction: Enter the mobile phone number of the health care provider who notified the case in the space provided.

 

 

NOTIFIERS SIGNATURE


 

Description: This field identifies the notifying healthcare provider signature as proof of identity.

Instruction:  Sign in the space provided.

 

Important to note that notification must be done by the health care provider who diagnosed the case. The health care provider details are required to enable acknowledgment of the notification and to provide the necessary feedback on the case.

 

Notifiable Medical Conditions

Notifiable under Section 90 (1) (j), (k) and (w) of National Health Act, 2003 (Act no. 61 of 2003)

 

Category 1 Notifiable Medical Conditions that require immediate reporting by the most rapid means available upon clinical or laboratory diagnosis followed by a written or electronic notification to the Department of Health within 24 hours of diagnosis by health care providers.

1. Acute flaccid paralysis
2. Acute rheumatic fever
3. Anthrax
4. Botulism
5. Cholera
6. Food borne illness outbreak
7. Malaria
8. Measles
9. Meningococcal disease
10. Plague
11. Poliomyelitis
12. Rabies (human)
13. Respiratory disease caused by a novel respiratory pathogen**
14. Rift valley fever (human)
15. Smallpox
16. Viral haemorrhagic fever diseases*
17. Waterborne illness outbreak
18. Yellow fever

 

 

Category 2 Notifiable Medical Conditions (NMC) that must be notified through a written or an electronic notification to the Department of Health within 7 days of diagnosis by health care providers

1. Agricultural or stock remedy poisoning
2. Bilharzia (schistosomiasis)
3. Brucellosis
4. Congenital rubella syndrome
5. Congenital syphilis
6. Diphtheria
7. Enteric fever (typhoid or paratyphoid fever)
8. Haemophilus influenzae type B
9. Hepatitis A
10. Hepatitis B
11. Hepatitis C
12. Hepatitis E
13. Lead poisoning
14. Legionellosis
15. Leprosy
16. Maternal death (pregnancy, childbirth and puerperium)
17. Mercury poisoning
18. Pertussis
19. Soil-transmitted helminth infections
20. Tetanus
21. Tuberculosis: pulmonary
22. Tuberculosis: extra-pulmonary
23. Tuberculosis: multidrug-resistant (MDR-TB)
24. Tuberculosis: extensively drug-resistant (XDR-TB)