Hepatitis B PMTCT Checklist Form
Checklist for Hepatitis B prevention of mother-to-child transmission (PMTCT) care workflow.
Date of Visit
*
-
Month
-
Day
Year
Date
Patient ID or Medical Record Number
*
Pregnancy Status
*
Please Select
First trimester
Second trimester
Third trimester
Postpartum
Hepatitis B Surface Antigen (HBsAg) Screening Completed
*
HBsAg test performed
HBsAg positive
HBsAg negative
Antiviral Prophylaxis Initiated (if indicated)
Tenofovir started
Not indicated
Hepatitis B Vaccine Administered to Mother
Dose 1 given
Dose 2 given
Dose 3 given
Infant Prophylaxis at Birth
HBV vaccine given within 24 hours
HBIG given within 12 hours
Infant Follow-Up Scheduled
First follow-up visit scheduled
Serology testing planned
Checklist of Preventive Actions Taken
Maternal counseling provided
Partner notified and tested
Infant registered for immunization
Completion Notes / Additional Comments
Submit
Should be Empty: