dialysis patient notification - black & white - msn.org.my · central delivery system g. f....
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Instruction to select boxes : 1) check one or more boxes 2) check one box only
Version 4.1 (NRR 2015)
< RM 1000
RM 1000 - 3000
RM 3001 - 5000
RM 5001 - 10000
> RM 10000
14. Primary renal disease(s) :
15.
16.
17.
Specify details :(Please specify details in text box)
Glomerulonephrities, specify
Diabetes Mellitus
Hypertension
Obstructive uropathy, specify
ADPKD
Drugs / toxic nephropathy
Hereditary nephritis, specify
Unknown
Others, specify
TB (any site)
d. Anti HCV antibody :
Other Malaysian, specify:
2. Identification card number :
Specify details :
Bumiputra Sarawak, specify:
Foreigner, specify:Malaysian
Bumiputra Sabah, specify:
(Specify details in box)
NRR ID:
SDPID:
Not done Not done
SKMBT
Hep. B antigen (HBsAg)
Hep. B antibody (HBsAb)
18.
19.
20. 21.
22.
RCF (Wrist AVF)
BBF Non-cuffed Catheter
Cuffed Catheter
Native graft
i. Dialysate Used
Solution A (Acid) + Bicarbonate Powder
Solution A (Acid) & B (Bicarbonate)
ii. Delivered dialysate electrolytes
Low (≤ 1.0)
Calcium (mmo/L)
High (≥ 1.75)
Normal (1.1 - 1.75)
Central delivery system
g.
f. Haemodialysis dialysate
23.
24.
Standard CAPD
Daytime Ambulatory PD
Automated PD / CCPD / NIPD
Others, specify :
Product / connectology, specifyBrand Name
Andy Disc
Stay Safe
Sleep Sa
Lucenxia
fe
Others, specify :
Ultrabag
HomeChoice / Pro
Ultraset
Others, specify :
25.
yad .62
27.
Religious Group reimbursed, specifyGovernment centres
JPA reimbursed
Others, specify
Government subsidy
SOCSO reimbursed
b. NGO / Charity body fundeda. Government funded
e. Insurancec. Self-funded
d. Employer subsidised f. Other source, specify
Voluntary Group reimbursed, specify
Others, specify
Others, specify :
Intellis