📊 PMC Monthly Medical Report Form for Rural Care

PMC Monthly Medical Report

Thank you for taking the time to complete this monthly medical report.
This form is a core tool of our Primary Medical Care program. It helps us document clinical activity, identify risks early, improve supervision, and strengthen patient safety across all field locations.

Please prioritise numbers and checkboxes whenever possible, and keep free text short and clinical. This report is not about perfection. It is about accuracy, consistency, and learning from real field conditions.

If you experience technical issues, connectivity problems, or have a medical question that requires clarification, please contact the coordination team directly via WhatsApp. Do not delay reporting because of a technical difficulty. Parallel communication is always acceptable in the field.

Your work and your reporting matter. Thank you for your commitment and professionalism.

PMC Monthly Clinical Report (Internal) v3

Structured monthly reporting for Primary Medical Care (PMC) field activities. Optimised for Mobile Devices, Low Bandwidth and Longitudinal Analysis.

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General & activity - Step 1 of 6 - PMC monthly report

Submission type*required

Real monthly report
Test / training submission

Select “Test” if you are practicing or checking the form. Test submissions will not be included in official statistics.

Monthly reporting, built for the field

Use numbers and checkboxes whenever possible. Keep free text short and clinical. This form is designed for low bandwidth and to produce comparable data month after month.

40 Report for the month of:

Example: Select the month for which this report is being written. Only one submission per month.

Of the year:

Select the current year

Sub-districts covered (kecamatan)

Kota Waingapu
Haharu
Kambata Mapambuhang
Kambera
Kanatang
Karera
Katala Hamu Lingu
Lewa
Lewa Tidahu
Matawai La Pawu
Ngadu Ngala
Nggaha Ori Angu
Paberiwai
Pahunga Lodu
Pandawai
Pinupahar
Rindi
Tabundung
Umalulu
Wula Waijelu
Kahaungu Eti
Mahu
Other area

Select all sub-districts covered in this report. Use “Other” only if the activity was outside the listed areas.

Main villages / hamlets (optional)

List key villages/hamlets covered (free text). Keep short. Use kecamatan tick-boxes below for the official area.

Other area (specify)

Short label only. No story. No patient identifiers.

Active Kawan Sehat agents (this month)

Selected Value: 20

Total agents working in the zone during this month.

Agents who submitted reports

Selected Value: 20

How many agents reported cases this month (App + WhatsApp + paper).

Medical supervisor / physician*required

Name of the supervising clinician responsible for this report.

Medical supervisor email*required

Professional email address used for clinical follow-up and report validation if needed.

If "Other", specify supervisor

Enter the name and role of the supervising clinician or coordinator.

Other email (if not listed above)

Enter a professional email address only if the supervisor’s email is not available in the list.

Overall Clinical Activity

Enter totals for the month. Use 0 if none.

Adults*required

Patients aged 15 years and above (or local standard).

Children*required

Patients aged under 15 years (or local standard).

Total patients (by age – automatic)*required

Automatically calculated from Adults + Children. This total is used for data consistency check and must match the total by sex below.

Female patients*required

Number of female patients included in this report (all ages combined).

Male patients*required

Number of male patients included in this report (all ages combined).

Total patients (by sex – automatic)*required

Automatically calculated from Female + Male patients. This total must be identical to the total calculated by age above.

Home visits

Consultations performed at the patient’s home.

Community consultations

Consultations done at schools, village office, or group sessions.

Referred to health facility

Patients referred for examination, tests, treatment, or escalation.

Clinical Case Distribution

Enter number of cases per condition. Keep categories stable over time.

Fever

Any febrile illness, any age.

Upper respiratory infections

Cough, rhinitis, sore throat, common cold symptoms.

Muscle pain / myalgia

Headache, back pain, joint pain, generalized body pain.

Wounds and trauma

Burns, cuts, bites, road accidents, sharp injuries.

Skin diseases

Dermatitis, fungal infections, secondary skin infections, urticaria/itch.

Diarrhea

Include suspected gastroenteritis and watery stools.

Eye conditions

Red eye, irritation, conjunctival symptoms.

Dental pain

Toothache, suspected dental infection.

Fatigue / weakness

Lemas, fatigue syndromes, low energy.

Other (count)

Number of cases not fitting the categories above.

Other (specify)

Short label only (no story). Example: epigastric pain.

Total clinical cases (automatic)

Automatically calculated from all case categories above. This total is used to check data consistency.

Cross-check total (manual entry)*required

Enter again the total number of patients seen this month. This must match the total patients reported in Section 2 (by age/sex). If different, explain below.

Explain discrepancy (if totals do not match)

Briefly explain why the totals differ (e.g. late entries, missing data, correction in progress, reporting issue).

Cases Requiring Special Attention

Tick red flags observed during the month. Use the brief description only for key signals.

Red flags observed (tick all that apply)

Persistent fever > 48 hours
Suspected malaria
Suspected tuberculosis
Infected wounds
Severe dehydration
Vision changes or severe eye symptoms
Altered consciousness or seizures
Other serious condition

These are clinical signals that usually require escalation, tests, or closer follow-up.

If 'Other serious condition', specify

Max 1 line.

Brief clinical description (max 3 lines)

Use only if needed: clusters, unusual severity, or safety issues. No patient identifiers.

Medical Supervision and Quality of Care

Quality signals help training and medication safety. Tick what occurred.

Quality flags observed

Medication duplication observed (paracetamol overlap)
Medication used outside proper indication
Stock shortages changed the treatment plan
Agent requested corrective medical guidance
Repeated cases requiring re-education
Incomplete treatment course
Deviation from standard treatment protocol
Others quality flag

These items are not blame. They are safety signals for supervision and supply planning.

If “Other”, specify quality flag

One short, factual description. No names or patient identifiers.

Key clinical issues this month (max 5 bullet points)

List the main recurring or critical clinical issues observed this month. Use short bullet points. No patient identifiers.

Prevention and Health Education Activities

Tick what was delivered. Estimate reach. Prevention is a clinical act in ultra-rural settings.

Activities conducted

Hygiene and handwashing education
Malaria prevention education
Diarrhea prevention and oral rehydration (ORS)
Smoking risk education
School-based education session
Water safety / clean water messages
Nutrition and malnutrition prevention education
Other

Choose all that apply. Keep this consistent month to month.

Other activity (specify)

Briefly describe the activity. Keep it short and factual.

Operational Constraints

Tick constraints that limited care, reporting, or safety.

Constraints encountered

Connectivity or network issues (App/reporting)
Medication restocking delay
Application error or device limitations
Agent absence (illness, maternity, travel)
Logistic constraints (road access, fuel, vehicle)
Security/weather disruption
Supply stockout (essential items unavailable)
Other constraints

These constraints guide planning, not judgment.

If “Other constraints”, specify

One short, factual phrase. No narrative.

Priorities and Needs for Next Month

Keep it short. Focus on what changes outcomes.

Priority 1

Highest priority action or need identified this month.

Priority 2

Additional priority if applicable.

Priority 3

Additional priority if applicable.

Medicines, consumables, and equipment

Tick what was missing or critically low at any point this month. Add details below.

Stockouts / critically low items (tick all that apply)

Paracetamol 500 mg
Ibuprofen 400 mg
Demacolin
Cetirizine 10 mg
Guaifenesin 100 mg
Antacids
DOEN
Norit
Oralit
Holizinc Tablet
Blood booster
Caviplex
Multivitamin
Amoxicillin
Povidone iodine 10%
Alcohol 70%
Ketoconazole cream 2%
Gentamicin cream 0.1%
Hydrocortisone cream 1%
Enbatic powder
Permethrin cream 5%
Insto eye drops
Ear cleaning solution
Sterile gauze
Elastic adhesive plaster
Latex gloves size L
Plastic medicine zip bags
Thermometer
Tweezers
Straight surgical scissors 12.5 cm
Nail scissors
Arm sling
Head lice comb
Eye wash cup

Focus on items that limited care.

Stockout details and resupply request

Which items, how long, which agent(s), and what quantity is needed. Add any urgent safety issues.

Data quality and reporting

Tick issues that affected data completeness or timeliness.

Reporting issues (tick all that apply)

AppSheet error / cannot submit
Phone damaged / lost
No signal / no internet
Cases entered late (after month end)
Incomplete therapy data entered
Duplicate entries / duplicate therapy observed
Staff unavailable (illness, leave, reassignment)
Other

Select what happened this month.

If 'Other', describe reporting issue

One short sentence.

Safety signals and red flags

Tick any event that requires immediate review by the medical team, even if it was already discussed in WhatsApp.

Critical events or red flags (tick all that apply)

Suspected severe malaria
Severe dehydration / suspected cholera-like diarrhoea
Seizure / epilepsy / febrile convulsion
Severe trauma (fall, head injury, burns)
Severe wound infection / necrosis
Pregnancy or postpartum emergency (bleeding, severe headache, vision changes)
Neonate or infant (<2 months) treated by agent
Suspected tuberculosis / leprosy / yaws requiring referral
Death in community related to illness
Other

Do not include identifiable patient details here.

If “Other”, specify critical event

One short, factual description. No patient identifiers.

Critical event summary (non-identifiable)

Describe what happened, which village/zone, what action was taken (referral, follow-up). No names.

Clinical coaching priorities

What should we reinforce next month? Keep it practical.

Training needs observed (tick all that apply)

Fever triage and danger signs
Wound care and infection recognition
Rational medicine use (no unnecessary antibiotics)
Paediatric dosing (kg-based)
Pregnancy/postpartum danger signs
Diarrhoea and dehydration management (ORS)
Respiratory infections (ISPA) management
Hypertension screening and follow-up
Other

Choose up to 5 if possible.

If 'Other', specify training need

One short sentence.

Attachments (optional)

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera

Camera Preview

Upload non-identifiable photos/documents only (no faces, no names). Use only if needed for review.

Validation

Active Key Report

Report completed by*required

Name of the person submitting this report.

Role*required

e.g., Field coordinator, nurse, physician.

Date*required

Date of submission.

Medical validation (optional)

If reviewed by physician, write name/initials.

Submission date*required

Date

Time

Date when this report is submitted.

Report reference (optional)

Internal code if you use one (e.g., PMC-UMALULU-2026-01). Leave blank if not used.

Internal clinical reporting form. Data are used for medical supervision, monitoring, and quality improvement only. No patient-identifiable information is stored.

Rumah Kambera 2.0 drilling marks the first physical step toward Fair Future Foundation’s new socio-medical base in East Sumba. After two days of work, fresh water was found, making future construction, field life, and patient care possible on the site.

The Zero Malaria Spot Radio

Interactive East Sumba map

PMC Monthly Medical Report

Rumah Kambera 2.0 Drilling Begins | Fair Future

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