Chronic Disease Register — Hypertension, Diabetes, COPD, Asthma
One line per patient, one page per condition: the last reading, the target, the next recall. The register is how a clinic stops losing people between visits
What it is
A paper or spreadsheet register template for the four commonest chronic conditions: patient, diagnosis date, last visit, key measure (BP, HbA1c, FEV1/symptom control), at target, medicines, next recall, missed recalls — with the monthly summary that becomes the clinic's quality indicator.
Where to use it
Every primary care clinic; reviewed monthly by the lead clinician; recall calls made from it. Evidence for: Primary Health Clinic Standard 4 — chronic-disease management; Standard 7 — population health. Evidence for: Primary Health Clinic Standard 4 — chronic-disease management; Standard 7 — population health. Evidence for: Primary Health Clinic Standard 4 — chronic-disease management; Standard 7 — population health. Evidence for: Primary Health Clinic Standard 4 — chronic-disease management; Standard 7 — population health.
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
Hypertension and Type 2 Diabetes — Treatment Protocol Cards
Vaccination — Schedule Card and Cold-Chain Temperature Log
Age-Friendly Primary Care — Checklist
Mental Health in Primary Care — Screening and First-Step Cards
Home Visit and Community Outreach Record
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