use this catalogue and original forms when … records/complete set...keep a master copy file in...

Health: KwaZulu-Natal Form Reference Number: Paed/D Clinical Records: Paediatrics

Catalogue for Paediatric Forms Use this Catalogue and Original Forms when Photocopying or Ordering Forms for Paediatric Wards and the Nursery

Form Description Use Catalogue Number Record Keeping Instructions: Children’s Ward Paediatrics Paed/C Cover Page: Paediatric Patient Record (boys and girls) Paediatrics Paed/07 Admission Sheet Paediatrics Paed/08 Growth Chart: 0-36 months weight and length Paediatrics Paed/09 Growth Chart: 2-20 years weight and length Paediatrics Paed/10 Growth Chart: 0-36 months coh Paediatrics Paed/11 Gastro Continuation Sheet Paediatrics Paed/14 Paediatric Discharge/Referral Letter Paediatrics Paed/23 HIV Testing, Clinical Staging & Care Plan Paediatrics Paed/24 Rheumatic Heart Disease Prophylaxis Letter Paediatrics Paed/25 Brain Death Checklist Paediatrics Paed/27 Rheumatic Heart Disease Follow Up Record Paediatrics Paed/28 Monitoring Sheet for Paediatric Transfers Paediatrics Paed/29 Monitoring Sheet In-transit Paediatrics Paed/30 Burns Chart for Body Surface Area Paediatrics Paed/32 Children’s Coma Score Paediatrics Paed/36 Paediatric Record Audit Paediatrics Paed/38 ARV Appointment and Prescription Record Paediatrics Paed/HIV1 Admission/Discharge Slip Paediatrics Paed/A&D Slip Record Keeping Instructions: Nursery Nursery Paed/A Use of Infant Care Record Nursery Paed/B Newborn Care Record (complete foldout) Nursery Paed/01 Weight and Intake Continuation Sheet: Neonate Nursery Paed/02 Clinical Notes Continuation Sheet: Neonate Nursery Paed/03 Growth Chart and Ballard Score: Neonate Nursery Paed/04 HIE Score: Neonate Nursery Paed/05 Basic Nursing Care: Neonate Nursery Paed/06 KMC Score Sheet Nursery Paed/26 Monitoring Sheet for Neonatal Transfers Nursery Paed/31 Jaundice Chart Nursery Paed/34 Neonatal Record Audit Nursery Paed/37 Neonatal Discharge/Referral Letter Nursery Paed/39 Results Both Paed/16 Acid Base, Blood Gasses and Ventilator Settings Both Paed/17 Oxygen Delivery, Saturation and Nebs Monitoring Sheet Both Paed/18 Glucose Monitoring Sheet Both Paed/19 Ventilator & CPAP Observations Both Paed/20 Intake-Output: IV and Orals Both Paed/21 Intake-Output: Orals Only Both Paed/22 Letter in Support of Grant Application Both Paed/33 Catalogue Both Paed/D Ordering Form Both Paed/E

Keep a Master Copy File in your ward, both as a quality control tool and to use for photocopying Do not photocopy copies Always ensure that the forms you use match the originals EXACTLY, front and back Incorrectly copied forms MUST be sent back to stationery stores Do not use forms other than these for the designated purpose

B y u s i n g t h e s e f o r m s c o r r e c t l y , w e w i l l i m p r o v e t h e q u a l i t y o f c a r e o u r p a t i e n t s r e c e i v e a n d w e w i l l s a v e t h e h o s p i t a l m o n e y , a n d w e w i l l s a v e o u r s e l v e s t i m e a n d f r u s t r a t i o n

Health: KwaZulu-Natal Form Reference Number: Paed/E Clinical Records: Paediatrics

Order Sheet for Paediatric Forms Use this Ordering Sheet and Original Forms when Photocopying or Ordering Forms for Paediatric Wards and the Nursery

Ward: Ordered By:

Date:

Form Description Quantity Catalogue Number Record Keeping Instructions: Children’s Ward Paed/C Cover Page: Paediatric Patient Record (boys and girls) Paed/07 Admission Sheet Paed/08 Growth Chart: 0-36 months weight and length Paed/09 Growth Chart: 2-20 years weight and length Paed/10 Growth Chart: 0-36 months coh Paed/11 Gastro Continuation Sheet Paed/14 Paediatric Discharge/Referral Letter Paed/23 HIV Testing, Clinical Staging & Care Plan Paed/24 Rheumatic Heart Disease Prophylaxis Letter Paed/25 Brain Death Checklist Paed/27 Rheumatic Heart Disease Follow Up Record Paed/28 Monitoring Sheet for Paediatric Transfers Paed/29 Monitoring Sheet In-transit Paed/30 Burns Chart for Body Surface Area Paed/32 Children’s Coma Score Paed/36 Paediatric Record Audit Paed/38 ARV Appointment and Prescription Record Paed/HIV1 Admission/Discharge Slip Paed/A&D Slip Record Keeping Instructions: Nursery Paed/A Use of Infant Care Record Paed/B Newborn Care Record (complete foldout) Paed/01 Weight and Intake Continuation Sheet: Neonate Paed/02 Clinical Notes Continuation Sheet: Neonate Paed/03 Growth Chart and Ballard Score: Neonate Paed/04 HIE Score: Neonate Paed/05 Basic Nursing Care: Neonate Paed/06 KMC Score Sheet Paed/26 Monitoring Sheet for Neonatal Transfers Paed/31 Jaundice Chart Paed/34 Neonatal Record Audit Paed/37 Neonatal Discharge/Referral Letter Paed/39 Results Paed/16 Acid Base, Blood Gasses and Ventilator Settings Paed/17 Oxygen Delivery, Saturation and Nebs Monitoring Sheet Paed/18 Glucose Monitoring Sheet Paed/19 Ventilator & CPAP Observations Paed/20 Intake-Output: IV and Orals Paed/21 Intake-Output: Orals Only Paed/22 Letter in Support of Grant Application Paed/33 Catalogue Paed/D Ordering Form Paed/E

Copied by: Date:

Issued by: Do not photocopy copies Always ensure that the forms you use match the originals EXACTLY, front and back Incorrectly copied forms MUST be sent back to stationery stores

B y u s i n g t h e s e f o r m s c o r r e c t l y , w e w i l l i m p r o v e t h e q u a l i t y o f c a r e o u r p a t i e n t s r e c e i v e a n d w e w i l l s a v e t h e h o s p i t a l m o n e y , a n d w e w i l l s a v e o u r s e l v e s t i m e a n d f r u s t r a t i o n

Health: KwaZulu-Natal Form Reference number: Paed/C Clinical Records: Paediatrics

Clinical Record Keeping: Paediatrics

T h e r e i s a s t a n d a r d s t r u c t u r e f o r P a e d i a t r i c R e c o r d s , a n d f o r f i l i n g o f n o n - c u r r e n t r e c o r d s .

T h e P a e d i a t r i c P a t i e n t R e c o r d i s k e p t i n t h e y e l l o w “ O u t p a t i e n t F o l d e r ” . H o w e v e r , t h i s i s N O T a n o u t p a t i e n t r e c o r d . T h i s i s t h e p a t i e n t c l i n i c a l r e c o r d t h a t f o l l o w s t h e p a t i e n t t h r o u g h o u t t h e

i n s t i t u t i o n , w h e n e v e r a n d w h e r e e v e r t h e p a t i e n t i s s e e n .

All Paediatric Patient Records are exactly the same (inside the yellow “outpatient” folder)

Section Healthworker responsible 1) Cover page Doctor 2) Growth chart: Birth to 36 months weight and height (boy chart facing) Doctor 3) Growth chart: Birth to 36 months head circumference (boy chart facing) Doctor 4) Growth chart: 2 to 18 years (boy chart facing) Doctor 5) Results sheet Doctor 6) HIV testing and staging sheet Doctor 7) Continuation pages/History and Progress/Referral Letters Doctor

T h e O P D c l e r k s o r n u r s i n g s t a f f s h o u l d a s s e m b l e t h e “ p a c k a g e ” a n d b i n d t h e m i n t h e y e l l o w f o l d e r s . C o n t i n u a t i o n p a g e s a n d r e f e r r a l l e t t e r s m u s t b e b o u n d c h r o n o l o g i c a l l y . S p e c i a l i n v e s t i g a t i o n r e p o r t s

( C T S c a n , e c h o e t c . ) c a n b e b o u n d a f t e r t h e H I V s h e e t , o r c h r o n o l o g i c a l l y . T h e o r d e r l i n e s s o f t h e P a e d i a t r i c P a t i e n t R e c o r d i s t h e r e s p o n s i b i l i t y o f t h e l a s t d o c t o r t o m a k e a n e n t r y .

All Paediatric Inpatient Records are exactly the same (inside ward-based “Ring Binders”)

All charts are in chronological order

Section Order Temperature charts Front to Back Doctor’s obs (results page, scoring sheets etc) Front to Back Nursing obs (“routine”, ventilator, phototherapy, etc) Front to Back Nursing Process Back to Front Intake/Output/Feeds Back to Front Prescription Back to Front Road to health chart Keep in a safe place and update when appropriate

1) Non-current pages are removed after one-two days 2) Results must be entered on results page, signed by attending doctor and filed away from the active record 3) Each page should have patient’s name and inpatient number 4) Notes should be problem orientated and focussed 5) If any change is made to the management of the patient, this change and the reason for the change must

be documented 6) When “filing” non-current pages, use a paper binder and keep pages in chronological order 7) When “filing” non-current pages, bind like with like 8) All the different kinds of pages (progress, prescription, intake/output, special observations etc.) used in the

department are standardised 9) ALWAYS RECORD THE CHILD’S DATE OF BIRTH, IN ALL DESIGNATED PLACES

“ G o l d S t a n d a r d ” f o l d e r s s h o u l d b e d e v e l o p e d f o r e a c h u n i t , a n d u s e d t o r e f e r t o f o r s t r u c t u r i n g f o l d e r s a n d t o c o m p a r e w i t h d u r i n g c h a r t r e v i e w m e e t i n g s .

Health: KwaZulu-Natal Form Reference number: Paed/07 Clinical Records: Paediatrics

Paediatric Patient Record Cover Page

Birth Registration/ID Number:

Name: OP Number:

Address: IP Number:

Date of Birth:

Phone Number: Gender: Male / Female (use sticker if available)

Date Problem (enter significant problems only) ICD Code Management

Admissions Register

DoA DoD Reason for Admission ICD Code Follow Up Place and Date

Name:________________________ Folder No:___________________

2

Background Information

Perinatal History

Antenatal Care: Site: Mother WR: + / - / ? Mother HIV: + / - / ?

Delivery: Mode: Place: Apgars:

Gestation: Birthweight: Length: COH:

Problems:

PMTCT: Not tested Mother Nevirapine: Y / N / ? Baby Nevirapine: Y / N / ?

Follow up site for PCR/Cotrimoxazole/CD4:

Vaccinations (insert date given, don’t tick) At birth: BCG: Y / N Polio: Y / N

Vaccine 6 weeks 10 weeks 14 weeks 9 months 18 months Preschool

Polio

DTP Td

HiB

Hep B

Measles

Vitamin A

Social History

Primary caregiver: Name: Relationship:

Household Income: Number of Dependents:

Qualifies for Grant: CSG / CDG / FCG Caregiver advised: Y / N Referral letter given: Y / N

Nutrition: Referred to Integrated Nutrition Programme: Y / N

Family History

Development (insert age achieved)

Smiled: _____ months Sat: _____ months Crawled: _____ months

Walked: _____ months Talked: _____ months School: Year _____ Grade: _____

Past Medical History (list admissions on first page)

Health: KwaZulu-Natal Form Reference Number: Paed/08 Clinical Records: Paediatrics

Paediatric patient admission sheet (to be completed by admitting doctor after usual clerking notes) Name: Date of Birth: DoA: ToA:

Admitted from Gender: m / f Admitting Doctor (print)

Admitting to ICU High

care Medical Surgical Mixed Receiving Doctor (print)

Outcome Discharged Transferred Absconded Died DoD: ToD:

Referred Name of hospital/clinic:

Ⓨ / Ⓝ / Ⓤ If yes, from: Another hospital A clinic Private sector Unknown

If yes, from: Inside drainage area Outside drainage area Unknown

Social Caregiver Name: Telephone:

Mother Alive and well Dead Sick Unknown Mother Grandmother

Father Alive and well Dead Sick Unknown

Primary caregiver

Father Other: _____

Nutrition OWFA Normal UWFA Marasmus Kwashiorkor M-K Unknown Weight: _____kg

HIV / AIDS Laboratory test Negative Exposed Infected No result Not tested

(but indicated) Not tested

(not indicated) Unknown

Clinical Stage I Stage II Stage III Stage IV Not staged (but indicated)

Not staged (not indicated) Unknown

PMTCT Prophylaxis given Prophylaxis not given Mother negative at delivery Unknown

Feeding in 1st 6 months

Exclusive breast for 6/12 No breast, ever Mixed, from birth Unknown

Cotrimoxazole Current Ever Never (but indicated) Never (not indicated) Unknown

ARV (child) Current Ever Never (but indicated) Never (not indicated) Unknown

ARV (mother) Current Ever Never (but indicated) Never (not indicated) Unknown

Main diagnosis/reason for admission Illness/Condition ICD 10

Basis for diagnosis (tick relevant)

Previous diagnosis Symptoms Signs

Current Rx:

Reasons for admission 1. Life-threatening problems (tick applicable)

Airway Critical Narrow Normal

Breathing Needs IPPV Needs oxygen Hyperventilation Normal

Circulation Shock (cap refill>3s) Hypovolaemia Hypervolaemia Normal

Consciousness (AVPU) Unconscious Response to Pain Response to Voice Alert

Convulsions In hospital Before arrival Past Never

Dehydration 10% 5% Oedema Normal

IMCI classification “Red” “Yellow” “Green”

Infection SIRS (“toxic shock”) Needs IV agent Needs oral agent No

2. Diagnostic workup (e.g. tuberculosis): 3. Social (e.g. poverty, distance, caregiver): 4. Specialist review/opinion:

5. Other:


2007/06/21 2

Priority problems / Red flags (circle applicable) 3 ‘T’s Tiny (< 2 months); Temperature (> 38°C or < 36°C); Trauma

3 ‘P’s Severe Pain; severe Pallor; Poisoning 3 ‘R’s Restlessness (or irritability or lethargy), Respiratory distress; urgent Referral

‘M’, ‘O’, ‘B’ Malnutrition; Oedema; Burns

readmission admitted within past 28 days for the same condition

last vaccine BCG / polio / diphtheria / pertussis / HiB / HepB / measles was / were given on: _______________

hypoglycaemia blood glucose < 2.6 mmol/ l Record actual blood sugar level:__________

Significant biochemical problems (record sats in room air FOR ALL ADMISSIONS & circle others applicable)

SpO2 in RA: pH < 7.2 K+ < 2.0 / K+> 6 Na+<120 Na+> 150 Albumin < 20

Urgent management Specific Rx Other Rx

Airway ETT: Bag/Mechanical IPPV:

Breathing Oxygen: Continue on way to ward:

Circulation/Shock Volume expand: Continue on way to ward:

Dehydration Rehydrate: Check Na:

Consciousness Protect airway: Coma position:

Infection IV antibiotic stat: Steroid/antipyretic:

Initial investigations (tick for “done”, circle for “to do”)

Chemistry acid-base renal FT’s liver FT’s blood glucose urine Na+ , K+ Urine protein:creatinine

Haematology FBC diff INR/PTT retics smear factorVIII/IX

Microbiology blood culture CSF urine dipstix urine MC&S stool MC&S Syphilis

Radiology chest X-ray abdo X-ray CT Brain MRI U/S Echo

TB skin test CSF Sputum AFB’s GW AFB’s Started TB Rx: yyyy/mm/dd

HIV rapid ELISA PCR CD4 Started ART: yyyy/mm/dd

Other Virus: Toxins/Drugs

Parameters for monitoring on arrival in ward (circle “to do”)

Temperature Respiratory rate

Sats/O2 requirement

Respiratory pattern Heart rate Blood

pressure Glucose Nurse

Weight Urine volume Stools Other:

Doctor Perfusion Acid-base Urea, creatinine

Serum Na+, K+ Hydration

Problem list and plans #1: #4:

Plan: Plan:

#2: #5:

Plan: Plan:

#3: #6:

Plan: Plan:

Pain Assessment No pain Mild pain Moderate pain Severe pain

Analgesia plan:

Sign: ________________________________ Date: ___________ Time: ___________

Health: KwaZulu-Natal Form Reference Number: Paed/A&D Slip Clinical Records: Paediatrics

*Admission / Discharge Slip (* delete whichever not applicable)

Attach this slip to Yellow File at admission, and to the Inpatient Records at discharge

Patient Name OP Number IP Number

Date Time Ward

Sign Contact Number MP Number

*Main reason for admission: *Discharge Diagnosis:





Date Time Ward







Date Time Ward



Paediatric Ward Admissions and Discharge Register Year:______________ Month:______________ Ward:__________________ Hospital:_________

No. Surname

Name Folder Number

Caregiver Name Telephone

Street, Town DoB Age DoA

ToA From? Weight

& Gender

Nutritionstatus: o/n/u/k/m/m-k

Diagnosis DoD ToD To?

ChIP reg y/n

Totals

DoB = date of birth; DoA = date of admission; ToA = time of admission; From? = enter where patient came from (e.g. another ward, home, clinic, another hospital); Nutrition status:o//n/u/k/m/m-k = overweight/normal/underweight for age/kwashiorkor/marasmus/marasmic-kwashiorkor; Dx = admission diagnosis (enter main reason for admission but update if diagnosis changes or child dies); DoD = date of discharge OR death; ToD = time of discharge OR death; To? = enter where patient was discharged to (e.g. another ward, home, clinic, POPD, another hospital, died); ChIP reg y/n = yes/no for entry on the Child PIP death register

L

E

N

G

T

H

L

E

N

G

T

H

W

E

I

G

H

T

W

E

I

G

H

T

Birth 3 96

Birth 3 1296 18 21 24 27 30 33 3615

2

3

4

5

6

7

10

12

14

16

8

6

kglb

AGE (MONTHS)

12 15 18 21 24 27 30 33 36kg

Mother’s Stature

Father’s Stature

Gestational

Date Age Weight Length Head Circ.

Age: Weeks

Birth

Comment

AGE (MONTHS)

8

9

10

11

12

13

14

15

16

17

90

95

100

cmcm

100

lb

16

18

20

22

24

26

28

30

32

34

36

38

40

45

50

55

60

65

70

75

80

90

95

85

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41in in

41

40

39

38

37

36

35

Birth to 36 months: Boys

L Weight-for-age percentilesength-for-age and

NAME

RECORD #

90

75

50

25

10

3

97

90

75

50

25

10

97

3

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Published May 30, 2000 (modified 4/20/01).

L

E

N

G

T

H

L

E

N

G

T

H

W

E

I

G

H

T

W

E

I

G

H

T

Birth 3 96

Birth 3 1296 18 21 24 27 30 33 3615

2

3

4

5

6

7

10

12

14

16

8

6

kglb

AGE (MONTHS)

12 15 18 21 24 27 30 33 36kg

Mother’s Stature

Father’s Stature

Gestational

Date Age Weight Length Head Circ.

Age: Weeks

Birth

Comment

AGE (MONTHS)

8

9

10

11

12

13

14

15

16

17

90

95

100

cmcm

100

lb

16

18

20

22

24

26

28

30

32

34

36

38

40

45

50

55

60

65

70

75

80

90

95

85

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41in in

41

40

39

38

37

36

35

Birth to 36 months: Girls

L Weight-for-age percentilesength-for-age and

NAME

RECORD #

90

75

50

25

10

97

3

90

75

50

25

10

97

3

SOURCE: Developed b

(2000).





2 to 20 years: Boys

Stature Weight-for-age percentiles-for-age and

NAME

RECORD #

W

E

I

G

H

T

W

E

I

G

H

T

S

T

A

T

U

R

E

S

T

A

T

U

R

E

lb

30

40

50

60

70

80

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

cm

cm

150

155

160

165

170

175

180

185

190

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

12 13 14 15 16 17 18 19 20

AGE (YEARS)

AGE (YEARS)

40

90

75

50

25

10

90

75

50

25

10

113 4 5 6 7 8 9 10

97

3

97

3

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

inDate

Mother’s Stature Father’s Stature

Age Weight Stature BMI*

SOURCE: Developed b

(2000).





2 to 20 years: Girls

Stature Weight-for-age percentiles-for-age and

NAME

RECORD #

W

E

I

G

H

T

W

E

I

G

H

T

S

T

A

T

U

R

E

S

T

A

T

U

R

E

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

cm

150

155

160

165

170

175

180

185

190

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

12 13 14 15 16 17 18 19 20

AGE (YEARS)

AGE (YEARS)

40

160

cm 113 4 5 6 7 8 9 10

90

75

50

25

10

90

75

50

25

10

97

3

97

3

lb

30

40

50

60

70

80

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

Date

Mother’s Stature Father’s Stature

Age Weight Stature BMI*

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

in

SOURCE: Developed b

(2000).





W

E

I

G

H

T

W

E

I

G

H

T

14

20

18

14

16

12

10

8

6

4

2

9

8

7

2

9

8

7

22

20

18

14

16

24

26

28

30

32

34

36

38

40

42

44

in

cm

kglb1

3

12

13

14

15

16

17

W

E

I

G

H

T

12

10

11

46

48

50

22

24

18

19

20

21

22

10

11

6

5

4

90

50

25

10

75

kg

in

cmLENGTH lb

6

5

Date Age Weight Length Head Circ. Comment

46 48 50 52 54 56 58 60 62

64 66 68 70 72 74 76 78 80 82 84 86 88 90 9290 94 96 98100

414039383735 36343332313029282726

24232221201918

97

3

Birth to 36 months: Boys

Head circumference-for-age and

Weight-for-length percentiles

NAME

RECORD #

12

Birth 3 1296 18 21 24 27 30 33 3615

52

50

48

46

44

42

40

38

36

32

cm

52

50

48

46

44

cm

20

19

18

17

16

15

14

13

in

20

19

18

in H

E

A

D

C

I

R

C

U

M

F

E

R

E

N

C

E

34

17

H

E

A

D

C

I

R

C

U

M

F

E

R

E

N

C

E

AGE (MONTHS)97

90

50

25

10

3

75

30

42

SOURCE: Developed b

(2000).





W

E

I

G

H

T

W

E

I

G

H

T

14

20

18

14

16

12

10

8

6

4

2

9

8

7

2

9

8

7

22

20

18

14

16

24

26

28

30

32

34

36

38

40

42

44

in

cm

kglb1

3

12

13

14

15

16

17

W

E

I

G

H

T

12

10

11

46

48

50

22

24

18

19

20

21

22

10

11

6

5

4kg

in

cmLENGTH lb

6

5

Date Age Weight Length Head Circ. Comment

46 48 50 52 54 56 58 60 62

64 66 68 70 72 74 76 78 80 82 84 86 88 90 9290 94 96 98100

414039383735 36343332313029282726

24232221201918

Birth to 36 months: Girls

Head circumference-for-age and

Weight-for-length percentiles

NAME

RECORD #

12

Birth 3 1296 18 21 24 27 30 33 3615

52

50

48

46

44

42

40

38

36

32

cm

52

50

48

46

44

cm

20

19

18

17

16

15

14

13

in

20

19

18

in H

E

A

D

C

I

R

C

U

M

F

E

R

E

N

C

E

34

17

H

E

A

D

C

I

R

C

U

M

F

E

R

E

N

C

E

90

50

25

10

75

30

AGE (MONTHS)

42

97

3

97

90

50

25

10

75

3

SOURCE: Developed b

(2000).






Name: ____________________________ Folder no:_____________________

Progress notes for diarrhoeal disease Date: ___________________________ Note: If ½DD, Ringer’s or formula is not appropriate, then delete and write in the alternative

Time/Weight Time: Weight: Time: Weight: Time: Weight:

Intravascular vol ↑vol Ⓝvol ↓vol imminent arrest ↑ ↔ ↓ ↑ ↔ ↓ O2 + fluid Rx Bolus _____ml Ringer’s Bolus _____ml Ringer’s Bolus _____ml Ringer’s

Hydration Over normal 5% 10% Over normal 5% 10% Over normal 5% 10%

Stools: no., type ___ normal / ___ forming / ___ watery ___ normal / ___ forming / ___ watery ___ normal / ___ forming / ___ watery

Vomiting Nil + ++ Nil + ++ Nil + ++

Drinking Eagerly poorly nil Eagerly poorly nil Eagerly poorly nil

Urine output ____ ml = ____ ml/kg/hour not monitored ____ ml = ____ ml/kg/hour not monitored ____ ml = ____ ml/kg/hour not monitored

Assessment Well improving ISQ worse Well ☺ Well ☺

Calculation of fluid volumes

and types needed

Ⓜ ____ ml/kg/24 X wt hrs = ____ ml

Ⓡ ____ ml/kg/24 hrs X wt = ____ ml

Ⓛ ____ ml/kg/24 hrs X wt = ____ ml

As before

Ⓜ ____ ml/kg/24 X wt hrs = ____ ml

Ⓡ ____ ml/kg/24 hrs X wt = ____ ml

Ⓛ ____ ml/kg/24 hrs X wt = ____ ml

As before

Ⓜ ____ ml/kg/24 X wt hrs = ____ ml

Ⓡ ____ ml/kg/24 hrs X wt = ____ ml

Ⓛ ____ ml/kg/24 hrs X wt = ____ ml

As before

(ml/24hrs) Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs

If NPO, give as: ½ DD: ____ ml/hr ½ DD: ____ ml/hr ½ DD: ____ ml/hr

If taking orally, give as:

breast on demand or EBM/formula ___ ml X 8 / 6

PLUS IV½ DD ____ ml/hr or ORS ____ ml/hr via

NGT OR

ORS: ____ ml per stool or ORS: ad lib



NGT OR




NGT OR


Other Problems

and plans


Name: ____________________________ Folder no:_____________________

Progress notes for diarrhoeal disease

Date: ___________________________ Note: If ½DD, Ringer’s or formula is not appropriate, then delete and write in the alternative

Time/Weight Time: Weight: Time: Weight: Time: Weight:

Intravascular vol ↑vol Ⓝvol ↓vol imminent arrest ↑ ↔ ↓ ↑ ↔ ↓ O2 + fluid Rx Bolus _____ml Ringer’s Bolus _____ml Ringer’s Bolus _____ml Ringer’s

Hydration Over normal 5% 10% Over normal 5% 10% Over normal 5% 10%

Stools: no., type ___ normal / ___ forming / ___ watery ___ normal / ___ forming / ___ watery ___ normal / ___ forming / ___ watery

Vomiting Nil + ++ Nil + ++ Nil + ++

Drinking Eagerly poorly nil Eagerly poorly nil Eagerly poorly nil

Urine output ____ ml = ____ ml/kg/hour not monitored ____ ml = ____ ml/kg/hour not monitored ____ ml = ____ ml/kg/hour not monitored

Assessment Well improving ISQ worse Well ☺ Well ☺

Calculation of fluid volumes

and types needed

Ⓜ ____ ml/kg/24 X wt hrs = ____ ml

Ⓡ ____ ml/kg/24 hrs X wt = ____ ml

Ⓛ ____ ml/kg/24 hrs X wt = ____ ml

As before

Ⓜ ____ ml/kg/24 X wt hrs = ____ ml

Ⓡ ____ ml/kg/24 hrs X wt = ____ ml

Ⓛ ____ ml/kg/24 hrs X wt = ____ ml

As before

Ⓜ ____ ml/kg/24 X wt hrs = ____ ml

Ⓡ ____ ml/kg/24 hrs X wt = ____ ml

Ⓛ ____ ml/kg/24 hrs X wt = ____ ml

As before

(ml/24hrs) Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs

If NPO, give as: ½ DD: ____ ml/hr ½ DD: ____ ml/hr ½ DD: ____ ml/hr

If taking orally, give as:



NGT OR




NGT OR




NGT OR


Other Problems and plans


Name:________________________ Folder No:___________________ HIV Testing and Clinical Staging Record, and Comprehensive Care Plan

Test Date Age (Child) Result Child: exposed / infected

/ not infected Caregiver informed/post

test counselled (date)

Mother’s serology

Child’s serology

Initial PCR

Initial CD4

ART Started

CD4 % at time of staging (enter the most recent result)

Staging (at every HIV check-up, sign each parameter present; if uncertain, insert “?”) Date

Stage I Asymptomatic Persistent generalized lymphadenopathy Stage II Hepatosplenomegaly Papular pruritic eruptions Seborrhoeic dermatitis Extensive human papilloma virus infection Extensive molluscum contagiosum Fungal nail infections Recurrent oral ulcerations Lineal gingival erythema (LGE) Angular chelitis Parotid enlargement Herpes zoster Recurrent or chronic RTIs (otitis media, otorrhoea, sinusitis) Stage III Moderate unexplained malnutrition not adequately responding to standard therapy Unexplained persistent diarrhoea (14 days or more) Unexplained persistent fever (intermittent or constant, for longer than 1 month) Oral candidiasis (outside neonatal period) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis / periodontitis Pulmonary TB Tuberculous lymphadenopathy (axillary, cervical or inguinal) Severe recurrent presumed bacterial pneumonia Unexplained anaemia (<8gm/dl), &/or neutropenia (<500/mm3) &/or thrombocytopenia (<50 000/mm3) for > 1/12 Chronic HIV-associated lung disease including bronchiectasis Symptomatic lymphoid interstitial pneumonitis (LIP) Stage IV Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy Pneumocystis pneumonia Recurrent severe presumed bacterial infection (eg empyema, pyomyositis, bone/joint inf, meningitis, but excl pneumonia) Chronic herpes simplex infection (orolabial or cutaneous of more than 1 month’s duration) Extrapulmonary TB Kaposi’s sarcoma Oesophageal candidiasis CNS toxoplasmosis (outside the neonatal period) HIV encephalopathy CMV infection (retinitis or infection of organs other than liver, spleen or lymph nodes; onset at age of ≥ 1 month) Extrapulmonary cryptococcosis including meningitis Any disseminated endemic mycosis (e.g. extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis) Cryptosporidiosis Isosporiasis Disseminated non-tuberculous mycobacterial infection Candida of trachea, bronchi or lungs Visceral herpes simplex infection Acquired HIV-associated rectal fistula Cerebral or B cell non-Hodgkin’s lymphoma Progressive multifocal leukoencephalopathy (PML) HIV-associated cardiomyopathy or HIV-associated nephropathy

If HIV infected or exposed, turn over for comprehensive HIV care plan/schedule


2007/06/08 2

Comprehensive Care Checklists for HIV Infected Children

Step Yes/No Date Done 1. Children < 1year: Stage 2-4 OR CD4 < 30%

Children 1 – 5 years: Stage 3-4 OR CD4 < 20% Children > 5 years: Stage 3-4 OR CD4 <15% (or absolute count < 200) OR Recurrent Complications*

2. Clinically eligible for ART **

3. ART site identified (name site ____________________________ )

4. Caregiver booked for ARV Clinic Social Worker to assess social circumstances (state date: _______ )

5. Caregiver advised to take Birth Certificate to ARV Clinic

6. Caregiver booked for Adherence Counselling (state site _________________________ )

7. Caregiver counselled on benefits of ART (state site ____________________________ )

8. Caregiver booked for ARV Clinic Dietician for nutritional assessment (state date: ____________ )

9. Caregiver/Mother’s own CD4 count checked (enter result: _____________ )

10. Caregiver/Mother has ART Clinic booking for herself (state date: _____________ )

Comment:

* Recurrent or prolonged hospitalisation for HIV related problems ** Once on ART programme, use Form Paed/HIV1: “Appointment and prescription Record for patients on ARV medicines”

If not eligible for ART use this checklist

Step Yes/No Date Done

1. Reason: social/medical (state reason: _________________________________________________ )

2. Caregiver advised that ART will eventually become necessary

3. Place for follow up identified (name site ____________________________ )

4. Caregiver informed of follow up site

5. Cotrimoxazole initiated (state date: _____________ )

6. Multivitamins initiated (state date: _____________ )

7. High dose Vitamin A given (state date: _____________ )

8. Dewormed (state date: _____________ )

9. Caregiver notified of next CD4 date (state date: _____________ )

10. Caregiver/Mother’s own CD4 count checked (enter result: _____________ )

11. Caregiver/Mother has ART Clinic booking for herself (state date: _____________ )

Comment:

Health: KwaZulu-Natal Form Reference Number: Paed/HIV1 Clinical Records: Paediatrics

Name:____________________________ Folder Number:__________________

Appointment and prescription record for patients on ARV medicines

Appointment Date MO initials

Pharm initials

Weight + Height CD4 Viral

Load Comment

Start treatment

First 2 week

1st month

2nd month

3rd month

4th month

5th month

6th month

7th month

8th month

9th month

10th month

11th month

12th month

Health: KwaZulu-Natal Form Reference Number: Paed/HIV1 Clinical Records: Paediatrics

Name:____________________________ Folder Number:__________________

Appointment Date MO initials

Pharm initials

Weight + Height CD4 Viral

Load Comment

2


This is a PATIENT HELD Record

Chronic Rheumatic Heart Disease: Antibiotic Prophylaxis

Re: Name of Patient: _________________________________________ Folder Number_______________________

The above patient has Chronic Rheumatic Heart Disease. The first episode of Acute Rheumatic Fever was in _______________. S/he is left with the following cardiac problems:

1. ______________________________________ 2. ______________________________________

3. ______________________________________ 4. ______________________________________

S/he should receive continuous penicillin prophylaxis as per the schedule below at EXACTLY 4 week intervals. Please could you dispense according to the schedule below. Please refer the child to the doctor if s/he has symptoms. S/he also receives the following treatment:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Please also supply these at the 4 weekly intervals.

Sign: _________________________

Penilente (LA) 1,2 MU IMI at 4 weekly or PenVK 250mg-500mg per os bd (if oral used, also indicate date of issue and date of next collection)

Date Due Date Given Place Given Signature INR Warfarin Dose

Indications for antibiotic prophylaxis against Infective Endocarditis

All dental procedures, including cleaning by a dental hygienist Childbirth

Any instrumentation of the gastro-intestinal, urinary, genital or upper respiratory tracts

Dental procedures

Antibiotics No anaesthetic: Penicillin Allergic:

>10 years Amoxicillin3 grams <10 years Erythromycin 500 mg <10 years Amoxicillin 1,5 grams >10 years Erythromycin 1 gram

Anaesthetic:

Penicillin or Amoxicillin equivalent


Chronic Rheumatic Heart Disease Follow Up Continuation Sheet

Name: __________________________________________ Folder No.: __________________________ Nearest Town: ________________________________ Nearest Clinic/Hospital: _______________________ (For monthly treatment)

Acute Rheumatic Fever Episode Date: _________________

Acute Rheumatic Fever Criteria (tick applicable) Evidence of preceding

Streptococcal infection Culture Rising ASOT Scarlet Fever None Unknown

Major Criteria Pancarditis Flitting Arthritis Chorea Erythema Marginatum

Subcutaneous nodules

Minor Criteria Long PR Interval Arthralgia Previous ARF/RHD Fever Raised

ESR/CRP/WCC

Date

Weight

Height

Pulse Rate

Blood Pressure

Prophylaxis letter checked

Effort tolerance/symptoms

CVS (anatomy & haemodynamics highlights)

CXR: CTR%

ECG: Chamber hypertrophy

Echo

IALCH last date/next date

Artificial Valve Candidate: y/n

Artificial Valve: y/n

INR/Warfarin

Medication

New Problems

Other Problems

Sign


Children’s Coma Score Sheet: children under 4 years Name: ______________________ Folder Number: _________________

Date Time

Eye opening Spontaneously 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

To verbal stimuli 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 To pain 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

No eye response to pain 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Best Motor Response

Obeys verbal command or moves normally 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Localise pain or withdraws to touch 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Withdraws from pain 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Abnormal flexion to pain (decorticate) 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Abnormal extension to pain (decerebrate) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 No motor response to pain 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Best Verbal Response Alert; babbles; coos; usual words and sentences 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Less than usual ability and/or spontaneous irritable cry 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Cries inappropriately 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Occasionally whimpers and/or moans 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 No verbal response to pain 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Total Suspected Phenobarb aetiology: Phenytoin Infection Benzodiazipine Trauma Opiate Seizures Thiopentone

Toxin Other CVA Pulse

Tumour BP Inborn error Respiratory rate

Other Left Pupil Right pupil

PTO for children 4 - 15 years


Children’s Coma Score Sheet: children 4-15 years Name: ______________________ Folder Number: _________________

Date Time

Eye opening Spontaneously 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

To verbal stimuli 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 To pain 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

No eye response to pain 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Best Motor Response

Obeys verbal command 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Localise pain 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Withdraws from pain 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Abnormal flexion to pain (decorticate) 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Abnormal extension to pain (decerebrate) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 No motor response to pain 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Best Verbal Response Orientated and converses 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Disorientated and converses 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Inappropriate words 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Incomprehensible sounds 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 No verbal response to pain 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Total Suspected Phenobarb aetiology: Phenytoin Infection Benzodiazipine Trauma Opiate Seizures Thiopentone

Toxin Other CVA Pulse

Tumour BP Inborn error Respiratory rate

Other Left Pupil Right pupil

PTO for children under 4 years


Checklist for Documenting Brain Death

Name:__________________________ Date of Birth:__________ Folder No.:_________

I Diagnosis Cause of Coma

II Laboratory Information 1. Blood Glucose Date&Time

2. CNS Depressing Drugs

Drug and dose Date&Time

Blood Level Date&Time

3. Toxicology Screen

III Clinical Examination Examiner 1 Examiner 2 Date

Time

Temperature

Blood Pressure

No spontaneous movements: (including no decorticate or decerebrate posturing or shivering)

Cranial Nerves

1. Pupils fixed and dilated

2. No corneal reflexes

3. No doll’s eye movement when head turned

4. No eye movement when auditory canals irrigated with ice water for 1 minute (clear tympanic membranes)

5. No cough when trachea suctioned

5. No motor response in cranial nerve distribution to painful stimulation

Apnoea Test (on IPPV: 100% O2 for 5 min then turn off IPPV for 5 min)

1. pCO2 at end of test

2. O2 saturation at end of test

3. pH at end of test

IV Isotope brain scan (if available) Date&Time V Having considered the above findings we certify the death: Examiner 1 Examiner 2

Date

Time

Signed

Print Name

From Red Cross War Memorial Children’s Hospital, Cape Town


Name:________________________ Folder No:___________________

Burns chart for assessing total body surface area burnt Use this chart on every child admitted with burns

Date of burn: _____________ Agent: ________________ Time of burn: ____________ Date of assessment: _____________ Time of assessment: ____________ Name (print): _____________ Sign: ____________


Date: Monitoring & handover sheet for paediatric transfers

(to be completed by referring and receiving doctors starting at time of referral) Time: Patient Name: Date of Birth: DoA: DoT:

1) REFERRING AND RECEIVING INFORMATION

Hospital Ward Doctor Designation Contact number

Referring Junior:

Senior:

Receiving Junior:

Senior:

2) CAREGIVER INFORMATION Accompanying

caregiver: Relationship: Contact number:

3) NUTRITION

OWFA Normal UWFA Marasmus Kwashiorkor M-K Unknown Weight: _____kg

4) HIV

Laboratory test Negative Exposed Infected No result Not tested (but indicated)

Not tested (not indicated) Unknown

Clinical Stage I Stage II Stage III Stage IV Not staged (but indicated)

Not staged (not indicated) Unknown

ARV Current Ever Never (but indicated) Never (not indicated) Unknown

5) CURRENT CONDITION (CIRCLE APPLICABLE) TIME:

Vitals Temp: PR: RR: Sats: Airway Critical Narrow Normal

Breathing Needs IPPV Needs oxygen Hyperventilation Normal Circulation Shock (Cap refill > 3s) Hypovolaemia Hypervolaemia Normal

Consciousness (AVPU) Unconscious Response to Pain Response to Voice Alert Convulsions In hospital Before arrival Past Never Dehydration 10% 5% Oedema Normal

IMCI classification “Red” “Yellow” “Green” Infection SIRS (“toxic shock”) Needs IV agent Needs oral agent No

6) SIGNIFICANT BIOCHEMICAL PROBLEMS (CIRCLE APPLICABLE)

Hypoxia (Sats in air____) Hypoglycaemia pH < 7.2 K+ < 2.0 K+> 6 Na+<120 Na+> 150 Albumin < 20

7) REASON FOR TRANSFER OR NON-ACCEPTANCE

Accepted(circle applicable): YES NO ICD 10

Main diagnosis / problem:

Other diagnoses / problems:

Prognosis for survival: Excellent Good Indeterminate Guarded

Prognosis for normal outcome: Excellent Good Indeterminate Guarded

Main reason for transfer / non acceptance:

8) URGENT MANAGEMENT

Specific Rx (circle or state) Other Rx Airway ETT / oral airway / none Oxygen delivery:

Breathing IPPV / Bag / Spontaneous Oxygen monitoring: Circulation/Shock Intra-osseous / peripheral IV / central IV / none Volume expand:

Dehydration IV / Oral ½ DD / ORS: Consciousness Protect airway: Coma position:

Infection IV antibiotic stat: Steroid / antipyretic:

9) PAIN ASSESSMENT

No pain Mild pain Moderate pain Severe pain Analgesia plan:


2007/06/26 2

10) ONGOING MONITORING AND RESPONSIBILITY WHILE AWAITING EMRS Name Rank Contact number

Doctor

Nurse

Time Temp Heart rate

Resp rate Sats Fi O2

O2 device

IV site secure

IV control device

IV rate AVPU score BP Gluc. Sign

On transfer

to ambulance

11) PROBLEMS ARISING AND THEIR PLANS WHILE AWAITING EMRS Problem Plan Discussed with Verified by

12) PATIENT TRANSPORT INFORMATION

Time accepted Receiving Hospital Doctor Rank Telephone Plan Sign

Time EMRS called EMRS Ops Centre Operator Designation Telephone Plan Sign

Time of EMRS arrival

Ambulance type Paramedic Designation Telephone Plan Sign

Time of departure, AND receiving

hospital notified

Receiving Hospital Doctor Rank Telephone Plan Sign

Time of arrival at receiving hospital Receiving Ward Doctor Rank Telephone Plan Sign

13) PATIENT HANDOVER

Handed over by Received by

Time Handover Point Name Designation Name Designation Sign

Referring hospital to EMRS

EMRS to receiving hospital

14) CAREGIVER PLAN

Name Relationship Contact number Breastfeeding Well/sick Plan for transport to receiving

hospital y/n

15) OUTCOME

Alive & not transferred

Died & not transferred

Died awaiting EMRS Died in transit

Died within 24 hours of transfer

Died beyond 24 hours of transfer

Alive and transferred back

to referring hospital

NB: this does not replace the usual referral letter containing ALL relevant clinical details; use the ‘Paediatric Discharge/Referral Letter’ proforma


Paediatric in-transit monitoring sheet (to be used by EMRS personnel)

Patient Name: Date of Birth: Date: Time:

1) REFERRING AND RECEIVING INFORMATION

Hospital Ward Doctor Designation Contact number

Referring Junior:

Senior:

Receiving Junior:

Senior:

2) REASON FOR TRANSFER

ICD 10

Main diagnosis / problem:

Other diagnoses / problems:

Prognosis for survival: Excellent Good Indeterminate Guarded

Prognosis for normal outcome Excellent Good Indeterminate Guarded

Main reason for transfer:

3) PAIN ASSESSMENT

No pain Mild pain Moderate pain Severe pain

Analgesia plan:

4) ONGOING MONITORING AND RESPONSIBILITY IN TRANSIT Name Rank Contact number Sign

Paramedic/EVC

Assistant



O2 device

IV site secure

IV control device

IV rate GCS BP Glucose Sign

In ambulance by EMRS

In ward by receiving

doctor

5) PROBLEMS ARISING AND PLANS IN TRANSIT

#1: #2:

Plan: Plan:

Discussed with: Discussed with:

6) PATIENT HANDOVER

Handover by Received by



If further recording is required, or if problems were encountered, use space overleaf


2007/06/08 2

Notes:

Problems encountered with the actual transfer:

Plan for reporting problems:


Paediatric Discharge/Referral Letter Hospital: Date: Patient Name: Date of Birth: DOA: Age:

Address: Gender: Male / Female DOD:

OP Number: Ward:

IP Number: Doctor in charge:

Referred by: Healthworker Clinic Hospital Private Practice

Name: Self

Outcome: Alive Dead Transferred to another hospital:

Dear Colleague Thank you for receiving the above-named patient. The child was found to have the following problems:

1 (main diagnosis) ICD Code

4 ICD Code

2 5

3 6

At admission the weight was ________ kg and the nutritional status was:

Normal UWFA Kwashiorkor Marasmus Marasmic Kwashiorkor

The discharge weight was ________ kg

Perinatal History

HIV and TB

HIV Date Age (Child) Result Child Exposed /

Infected / Not infected Caregiver informed

(date) Mother’s serology

Child’s serology Initial PCR

Current CD4 ART Started

Clinical stage 1 2 3 4 Not staged Tuberculosis Contact: Skin test: CXR: Rx started:

Vaccinations

Up to Date Incomplete → action taken:

Social History

Qualifies for Grant: CSG / CDG / FCG Caregiver advised: Y / N Letter given: Y / N

Family History

Development

Normal Delayed → action taken:

Past Medical History

2007/06/26 2

Progress in the ward (document each problem, and its management and course, separately)

Prescription at discharge (drug AND dose)

1 4

2 5

3 6

Future plans and follow up arrangements (including for HIV) Problem Follow up date Follow up venue

Remarks

The Road to Health Chart was checked and updated Yes No Not present Yours sincerely

Sign: _______________________ Print/Stamp: _____________________ Date: _________________

Contact Number: ______________________


P A E D I A T R I C R E C O R D A U D I T DATE: ___________________________ HOSPITAL: ___________________________ DATE OF PATIENT’S ADMISSION: ___________________________ PATIENT’S DIAGNOSIS: ___________________________

Check each document for the following:

Paediatric Patient Record A. PATIENT’S DETAILS: N/C P/C C COMMENTS Name and Initials recorded on very page Hospital number recorded on every page Date of birth recorded wherever indicated Name and contact details for primary care giver clearly recorded wherever indicated

C. DOCUMENTATION Standardised Paediatric Record Keeping system used Record compiled exactly according to policy Clinical notes, including referral letters, in chronological order Clinical notes, including referral letters are legible Identifiable name on every entry Cover page filled in Second page (background information) filled in Weight plotted on growth chart Results sheet filled in Signature on all results/reports of investigations e.g. bloods, x-rays, etc.

HIV testing and staging filled in Admission times recorded Consultation times recorded Appropriate history taken Appropriate clinical examination performed Requests of special diagnostic tests documented Details of medical findings leading to a diagnosis are recorded An assessment of the child’s problems is recorded A comprehensive problem list is recorded A plan is made for each problem Treatment prescribed, in notes, and on prescription sheets Intake (oral and IV when indicated) in notes and intake/output sheet Nursing orders are clearly documented Every consultation/clinical encounter with patient is recorded Every referral to other services is recorded clearly The findings and plans of other services involved in the patient’s care are clearly documented

Abbreviations are kept to a minimum or made clear

Last modified: 15 June 2007 For review: 2007 2

D. INFORMATION FOR PARENTS / CARE GIVER N/C P/C C COMMENTS Carer/child is informed of diagnoses and problems and this is documented

Carer/child is informed of management/treatment plan and this is documented

Carer/child is informed of prognosis and this is documented Patient and carer participate in decision-making relating to treatment, and same documented

Informed consent is obtained when necessary and this is documented

E. DISCHARGE OF PATIENTS Unresolved problems at discharge are clearly stated and documented Follow-up plans (including places and dates) for each problem are agreed with patients and carers by doctors prior to discharge and documented

Discharge medication (drugs and dosing) clearly documented in the discharge letter

Discharge summary in the paediatric patient record and a copy filed in the ward

Adequate Health Education is given to caregivers during hospitalisation and on discharge

GENERAL OVERVIEW / COMMENTS This paediatric patient record reflects quality medical care This paediatric patient record reflects comprehensive care The guideline on quality paediatric record keeping was followed If this was my own child, I would be happy with this clinical record Auditor’s name: ___________________________ Signature: _______________________ Outcome of audit Reported by: ____________________________________ Reported to: ____________________________________ Date: ____________________________________ Rating: Non-compliant (n/c) = 0 Partially compliant (p/c) = 1 Compliant (c) = 2

Health: KwaZulu-Natal Form Reference number: Paed/A Clinical Records: Paediatrics

Clinical Record Keeping in the Nursery

It is a good idea to standardise the structure for Neonatal Inpatient Folders, and for filing of non-current records.

An example, which REALLY works, follows.

All charts must be exactly the same (inside Ring Binders) Section (each section separated by a file divider) Healthworker responsible

1) Patient’s clinical notes Doctor

2) Doctor’s obs (results page, scoring sheets etc) Doctor

3) Nursing obs (“routine”, ventilator, phototherapy, etc) Nurse

4) Nursing Process Nurse

5) Intake/Output/Feeds Nurse

6) Prescription Doctor and Nurse to check all sheets every day

7) Road to Health Chart Doctor and Nurse to fill in relevant sections when appropriate

8) Miscellaneous “Clearing House” for anything awaiting filing (empty daily)

All charts are in chronological order Section Order

Baby’s clinical notes Front to Back

Doctor’s obs (results page, scoring sheets etc) Front to Back

Nursing obs (“routine”, ventilator, phototherapy, etc) Back to Front

Nursing Process Back to Front

Intake/Output/Feeds Back to Front

Prescription Back to Front

Important instructions Non-current pages are removed after one - two days

This applies to all sections except patient’s clinical notes Results must be entered on results page, signed by attending doctor and filed Each page should have patient’s name and hospital number Notes should be problem orientated and focussed If any change is made to the management of the patient, this change and the reason for the change must be

documented When “filing” non-current pages, use a paper binder and keep the pages in chronological order When “filing” non-current pages, bind like with like All the different kinds of pages (progress, prescription, intake/output, special observations etc.) used in your

unit/department should be standardised

Each Ward should have a “Gold Standard” folder to refer to for structuring folders, and to compare with during chart review meetings.

Health: KwaZulu-Natal Form Reference Number: Paed/B Clinical Records: Paediatrics

Using the Newborn Care Record

Using the Infant Care Record, and following these instructions for its use will immediately enable the improvement of the quality of care babies receive, and will make your looking after them more efficient

ALWAYS PRINT YOUR NAME CLEARLY Newborn Care Record: 1st page (ALL live births) 1. Birth attendant (midwife and/or doctor) to fill in all maternal and resuscitation details, marking where necessary the

appropriate response boxes. Where pregnancy, labour and/or delivery problems are noted, give detail on Page 3 in the space provided

2. The apgar scores should be transposed from the table on the back page 3. Birth attendant’s name MUST appear in the bottom right corner 4. When WR is positive, write in the titre in the space provided 5. When filling in the weight scale, start in the space provided between 36 and 37 degrees. Use weight gradations of

50 grams 6. The front page becomes the daily snapshot of the clinical course 7. When babies stay longer than 14 days, use the continuation weight/temperature chart, but start the weight scale in

the space provided between 34 and 35 degrees, and continue using weight gradations of 50 grams 8. The “Problem List” is to be filled in, as problems are identified (don’t use this space for clinical notes, or X-ray

registers e.t.c.). Start getting into the habit of entering the ICD 10 codes as well

2nd page (ALL live births) 1. Birth attendant to fill in information on previous pregnancies and on the placenta, and to complete the relevant

identification section 2. When urine or meconium are passed or when abnormalities are noted, these should be documented on the

“Examination check list” even if they are noted at a time prior to the formal First Examination 3. First examination table to be completed by the person performing the first examination. This should be done within

24 hours of delivery. Remember to print your name and sign

3rd page (only if problems - no matter how trivial - are encountered) 1. Insert the referral letter here if there is one 2. Details of abnormalities during pregnancy, labour and or/delivery to be documented in the space provided 3. Clinical “First Contact” notes start below this. Doctors AND nurses can use the same pages for clinical notes 4. List the significant problems on the front page as well 5. Clinical notes continue on page 5 (using a ‘ring-binder’)

4th page 1. Use the “Apgar Scoring Chart” to score all babies. Transpose the totals to the space provided on page 1.

Remember to print your name and sign 2. A 10 minute apgar need only be done if the baby needs ongoing resuscitation 3. On the “Discharge Check and Plan”, the “Unresolved Problems” list should only be completed at discharge

Continuation Pages 1. Number continuation pages starting from 5 2. Write patient registration details on each page, or use a sticker

Referring When referring or transferring baby to another facility, the Newborn Care Record or a photocopy thereof should travel with the baby (this makes writing a long referral letter unnecessary). Any additional information in a referral letter should be in duplicate, the original with the patient, and the copy in the folder as a clinical record kept in chronological order with the rest of the clinical notes.

Health: KwaZulu-Natal Form reference number: Paed/01 Clinical Records: Paediatrics

Page 1

MOTHER Baby’s Name: Baby’s Number: Birthweight (g)

Name:

Gender: ♂ / ♀ Address: Length (cm)

Folder Number:

Age: Grav: Para: Date of Birth: (use sticker when available)

COH (cm)

Pregnancy Received ANC: ⓎⓃTime of birth NVD Breech Assisted C/S LMP (mm/yy) / EDD /

Date

VDRL/WR: ⊕ ⊖

Titre:1/ Rx X 3: ⓎⓃPCV/Hb

Blood Group: Antibodies: ⓎⓃTSB

Hypertension/PIH: ⓎⓃ Diabetes: ⓎⓃPhototherapy

TB: ⓎⓃ Cardiac: ⓎⓃWeight(g) ℃ m e m e m e m e m e m e m e m e m e m e m e m e m e m e Epilepsy: ⓎⓃ APH: ⓎⓃ

Alcohol: ⓎⓃ Smoker: ⓎⓃ40 Labour Induced: �� ROM: hrs

1st Stage: hrs 2nd Stage: mins

Pyrexia: ⓎⓃ AB’s: ⓎⓃ

39 Analgesia: ⓎⓃ Foetal distress: ⓎⓃBABY

Apgar:1min 5 min 10 min

Resuscitation 38

MSL: ⓎⓃ SuctionedⓎⓃAction: None: ⓎⓃ Oxygen: ⓎⓃ

Mask ventilation: ⓎⓃ ETT+IPPV: ⓎⓃ37 Drugs:

‘Distress’ Indicators: TSR: (mins)

Cord pH: Cord BE:

36 Cord Blood

Group: Coombs: ⊕ ⊖ WR: ⊕ ⊖Gestational Age Estimate: weeks

US: weeks Scored: weeks35 AGA UGA OGA

MTCT: Mother ⊕ /⊖ /? Breast / Formula

Mother NVP: Ⓨ/Ⓝ/?/na Baby NVP: Ⓨ/Ⓝ/?/na

34 Problem List ICD

Antibiotic 1

Antibiotic 2

% Oxygen

IPPV / CPAP

Other:

Feed

s

IV (ml/hr)

ml/kg/day

Birth Attendant Print: Sign:

Age (day) Put to breast in LW? Ⓨ Ⓝ

First Examination (mark the appropriate block) Previous Pregnancy Appearance Well Sick Dysmorphic Year Abnormalities

Temperature 36-37 °C Hypothermic Hyperthermic 1.

Nutrition Well nourished Obese Wasted 2.

Odour Normal Offensive 3.

Behaviour Responsive Lethargic Irritable Jittery 4.

Colour Pink Blue Plethoric Pale Jaundice 5.

Apex bpm 120-160 /min Tachycardia Bradycardia Murmur Placenta Breast/Nipples Normal Wide-spaced Engorged Discharging Accessory Weight:

Resp. rate 40-60 /min Fast Slow Irregular Appearance:

Chest movement Symmetrical Asymmetrical Shallow Clots:

Recession Absent Costal Sternal Number of Cord vessels:

Breath sounds Quiet Grunting Noisy Cord knots:

Abdomen Normal Distended Scaphoid Large liver Large spleen Recorded by (print):

Umbilicus Normal Moist Flare Bleeding Mec. stained Vitamin K given

Femoral pulses Present Absent Site Date:

Genitalia: Male Testes down Undescended Hydrocoele Inguinal hernia Hypospadias Print name: Sign:

Genitalia: Female Normal Ambiguous Eye prophylaxis given Date:

Urine Passed Not passed Print name: Sign:

Anus Patent Imperforate Identification Meconium Passed Not passed At Birth Date:

Hips Normal Dislocated Dislocatable Midwife (print): Sign:

Legs Normal Not moving Asymmetrical Witness (print): Sign:

Feet position Normal Posit. deformity Clubbed Mother (print): Sign:

Toes Normal Polydactyly Syndactyly (or) Mother’s Thumbprint

Arms Normal Not moving Asymmetrical

Palmar creases Normal Single

Fingers Normal Polydactyly Syndactyly

Grasp reflex Present & equal Weak Absent

Moro reflex Present & equal Asymmetrical Weak Absent Nursery Date

Clavicles Intact Fracture Brought by (print): Sign:

Suck reflex Present Weak Absent Received by (print): Sign

Mouth Normal Smooth philtrim Cleft lip Ward Date:

Palate Intact Cleft hard Cleft soft Brought by (print): Sign:

Tongue Normal Large Protruding Received by (print): Sign

Chin Normal Small Mother (print): Sign:

Face Symmetrical Asymmetrical Abnormal (or) Mother’s Thumbprint

Nose Patent Blocked

Eyes Normal Small Large Slanting Infected

Ears Normal Abnormal Low position

Neck Normal Swellings Webbed

Back Normal Meningocoele Sacral dimple Hair tuft Scoliosis Footprint Head shape Normal Asymmetrical Caput Haematoma Trauma

Fontanelles Normal Bulging Large Third Sunken

Sutures Mobile Overriding Widened Fused

Muscle tone Normal Hypotonic Hypertonic Skin Intact Bruising Rash Purpura

Cry Normal Hoarse High-pitched Weak Absent

Assessment:

Assessed by (print name): Sign:

Date: Time:

Clinical notes are continued on page 5

Date Abnormalities in Current Pregnancy and Labour Print name

Date Time First Contact Notes Print name

Apgar Scoring Chart (circle appropriate number, an accurate score is essential) Assessment 1 Minute 5 Minutes 10 Minutes

None 0 0 0 Heart rate Less than 100 1 1 1

More than 100 2 2 2 Absent 0 0 0

Respiration Weak/Irregular 1 1 1 Good/Cries 2 2 2 Central Cyanosis 0 0 0

Colour Peripheral Cyanosis 1 1 1 Peripherally Pink 2 2 2 Limp 0 0 0

Tone Some Flexion 1 1 1 Active/Well Flexed 2 2 2 None 0 0 0

Response to stimulation Some Response 1 1 1 Good Response 2 2 2

Total Score /10 /10 /10

Scored by: Print name Sign Date

Pre-discharge Checklist

Checked by: Pint Name: Sign: Date:

Feeding well y n Breast fed y n Eyes normal y n Jaundice y n

Cord infection y n Cord stump normal y n Meconium passed y n Urine passed y n

BCG given y n Polio given y n Health Education given: Buttock care y n Infant feeding y n

Cord care y n General hygiene y n RTHC filled in y n RTHC instruction y n Birth registration done y n

Unresolved problems at discharge Plan at discharge (include Rx)

1.

2.

3.

4.

5.

Follow up place: Follow Up date:

PMTCT site: PMTCT date:

Discharged by (Print Name): Sign: Designation:

Discharged to (Print Name): Sign: Relationship:

Identified by ID: (or) Thumbprint

Abbreviations: ANC=antenatal care, (g)=grams, (cm)=centimetres, COH=circumference of head, Grav=gravida, Para=parity, EDD=estimated date of delivery, PMTCT=mother to child transmission prevention, VDRL=syphilis serology, TB=tuberculosis, APH=antepartum haemorrhage, MSL=meconium stained liquor, ETT+IPPV=endotracheal tube plus ventilation, TSR=time to spontaneous respiration, Cord pH=acidity of cord blood, Cord BE=base excess of cord blood, ICD=international classification of disease, PCV=packed cell volume, TSB=total serum bilirubin, IPPV=intermittent positive pressure ventilation, CPAP=continuous positive airways pressure, IV=intravenous, ml/kg/day=millilitres per kilogram per day, LW=labour ward, Resp.=respiration, Posit.=Positional, BCG=TB vaccine, RTHC=road to health card, (mm/yy)=month/year, NVP=nevirapine (or alternative), PMTCT=prevention of mother to child transmission, AGA/UGA/OGA=appropriate/underweight/overweight for gestational age


Page _____

Fold page to ascertain centre for punching holes prior to cuttingWrite patient’s name on the back of the sheet (or use sticker)

⇐ Cut here

Date

PCV/Hb

TSB

Phototherapy

Weight(g) ℃ m e m e m e m e m e m e m e m e m e m e m e m e m e m e

40

39

38

37

36

35

34

Antibiotic 1

Antibiotic 2

% Oxygen

IPPV / CPAP

Fee

ds

IV (ml/hr)

ml/kg/day

Age (day)

⇓


Name: __________________________ Folder Number: _______________________

PAGE _____

Date&Time Problem Clinical Notes Investigation Management


Name: ______________________________ Folder Number: _______________________ Date of Birth: ______________

Dubowitz/Ballard Exam for Gestational Age Physical Maturity -1 0 1 2 3 4 5

Skin Sticky, friable, transparent

Gelatinous red, translucent

Smooth pink, visible veins

Superficial peeling and/or rash, few veins

Cracking, pale areas, rare

veins

Parchment, deep cracking,

no vessels

Leathery, cracked, wrinkled

Lanugo None Sparse Abundant Thinning Bald areas Mostly bald

Plantar Creases

Heel-toe 40-50 mm = -1,

Heel-toe >50 mm, no creases Faint red marks

Anterior transverse crease

only

Creases over anterior 2/3

Creases over entire sole

Breast Imperceptible Barely perceptible

Flat areola, no bud

Stippled areola, 1-2 mm bud

Raised areola, 3-4 mm bud

Full areola, 5-10 mm bud

Eye & Ear Lids fused, loosely = -1, tightly = -2

Lids open, pinna flat, stays

folded

Slightly curved pinna, soft with

slow recoil

Well-curved pinna, soft but ready recoil

Formed and firm, with

instant recoil

Thick cartilage, ear stiff

Genitals, male

Scrotum flat, smooth

Scrotum empty, faint rugae

Testes in upper cannal, rare

rugae

Testes descending, few

rugae

Testes down, good rugae

Testes pendulous, deep

rugae

Genitals, female

Clitoris prominent, labia flat

Prominent clitoris, small labia minora

Prominent clitoris,

enlarging minora

Majora and minora equally

prominent

Majora large, minora small

Majora cover clitoris and

minora

Physical Score: ________

Neuromuscular Maturity

Neuromuscular Score: _______

Total Score: _______ Maturity Rating: _______

Maturity Rating Add up the individual Physical and Neuromuscular maturity scores for the twelve categories, then obtain the estimated gestational age from the table below.

Total Score

Gestational Age, Weeks

-10 20 -5 22 0 24 5 26 10 28 15 30 20 32 25 34 30 36 35 38 40 40 45 42 50 44

Plot weight on the growth chart overleaf, then decide on:

OGA AGA UGA (overweight for gestational age) (appropriate for gestational age) (underweight for gestational age)

Last modified: 08 June 2007 For review: 2009


Last modified: 08 June 2007 For review: 2009


Hypoxic Ischaemic Encephalopathy Score Sheet Name: ______________________ Folder Number: _________________

Date of Birth: _______________

Sco re at D e

Sign 0 1 2 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Tone Normal Hyper Hypo Flaccid

LOC Normal Staring Lethargic Comatose

Fits None <3/day >2/day

Posture Normal Fisting Frog-like Decerebrate

Moro Normal Partial Absent

Grasp Normal Poor Absent

Suck Normal Poor Absent +/-bites

Respiration Normal Hyper Apnoea IPPV

Fontanelle Normal Full Tense

Comment on labour, delivery, resuscitation Total

Phenobarb

Magnesium

Clonazepam

Midazolam

Valium

Other


Neonatal Jaundice Monitoring Chart: Phototherapy

Name: Folder No:

Date of birth: Time of birth:

Birthweight: Gestation:

Baby’s Blood Group: Baby’s Coomb’s: Mother’s Blood Group

U s e “ E x c h a n g e T r a n s f u s i o n ” c h a r t o ve r l e a f i f E X C H AN G E T R AN S F U S I O N i s a p o s s i b i l i t y

PHOTOTHERAPYWESTERN CAPE 2006 CONSENSUS GUIDELINES In presence of risk factors use one line lower (the gestation below) until <1000g.

If gestational age is accurate, rather use gestational age (weeks) instead of body weight

Start intensive phototherapy when the TSB is ≥ the line accordinStart intensive phototherapy when the TSB is ≥ the line according to gestation or weight.g to gestation or weight.

Infants under phototherapy : Check the TSB 12 – 24 hly but if TSB >30 μmol/L above the line , check TSB 4 – 6hly.STOP phototherapy :If TSB > 50 μmol/L below the line. Recheck TSB in 12 – 24hr.

340320300280260240220200180160140120100

806040200

Micr

o mo

l / L

TSB

(tota

l ser

um b

ilirub

in)

Time (age of baby in hours)6h 12h 24h 36h 48h 60h 72h 84h 96h 108h 120h

XXX XX X X

X

X38+ wks or 3000+g35 – 37w6d or 2500 – 2999g34 – 34w6d or 2000 – 2499g32 – 33w6d or 1500 – 1999g30 – 31w6d or 1250 – 1499g28 – 29w6d or 1000 – 1249g<28w or <1000gX

Infants > 12 hours old with TSB level below threshold, repeat TSB level as follows: 1- 20μmol/L below line:repeat TSB in 6hrs or start phototherapy and rept TSB in 12- 24hrs,21 - 50 μmol/L below line: repeat TSB in 12 – 24hrs, >50 μmol/L below line: rept TSB until it is falling and/or until jaundice is clinically resolving

Name:________________________ Folder No:___________________

Neonatal Jaundice Monitoring Chart: Exchange Transfusion

EXCHANGE TRANSFUSIONWESTERN CAPE 2006 CONSENSUS GUIDELINES

In presence of sepsis, haemolysis, acidosis, or asphyxia, use one line lower (gestation below) until <1000g

If gestational age is accurate, rather use gestational age (weeks) than body weight

Note: 1. Infants who present with TSB above threshold should have Exchange done if the TSB is not expected to be below the threshold after 6 hrs of intensive phototherapy.

2. Immediate Exchange is recommended if signs of bilirubin encephalopathy and usually also if TSB is >85 μmol/L above threshold at presentation

3. Exchange if TSB continues to rise >17 μmol/L/hour with intensive phototherapy

Time (age of baby in hours) 6h 12h 24h 36h 48h 60h 72h 84h 96h 108h 120h

450440430420410400390380370360350340330320310300290280270260250240230220210200190180

Micro

mol

/ L T

SB (t

otal s

erum

biliru

bin)

38+ wks or 3000+g35 – 37w6d or 2500 – 2999g34 – 34w6d or 2000 – 2499g32 – 33w6d or 1500 – 1999g30 – 31w6d or 1250 – 1499g28 – 29w6d or 1000 – 1249g<28w or <1000g

XX X XX X X

X

X X

X

R e c o r d a l l T S B ’ s , H b / P C V ’ s , p h o t o t h e r a p y , b a b y ’ s g r o u p a n d C o o m b ’ s , a n d m o t h e r ’ s g r o u p i n t h e d e s i g n a t e d p l a c e s o n t h e “ N e w b o r n C a r e R e c o r d ” ( F o r m P a e d / 0 1 )

2


Name:________________________ Folder No:___________________

Basic Neonatal Care Nursing Observations: ______ hourly

Date Time Incubator Tº Baby Tº Glucose * Oxygen:

y/n** Pulse Rate Sats (%) Blood

Pressure Active and responsive:

y/n

Buttocks clean and dry: y/n

Mouth Care Cord care Eye care Skin care

Old strapping removed:

y/n

Drip site OK: y/n

Sign

* If baby’s glucose is less than 2.5mmol/l, use hypoglycaemia monitoring sheet

** If baby is on oxygen, use oxygen monitoring sheet

PAGE ___


Name:________________________ Folder No:___________________

KMC Daily Score Sheet Date

Date of birth: KMC start date: Day

Feeding choice: Breast / Formula PMTCT: yes / no Weight

Score 0 1 2 Intermittent (I)or Continuous (C) I/C

Breast fed Score here for exclusive breast feeding

Mom's milk production None Not enough Enough Must score 2 before discharge

Positioning at breast Needs help Some help needed No help needed

Baby's ability to suckle at breast Tube fed Breast AND cup or tube Mainly breast

Formula fed Score here for formula feeding Knowledge of formula preparation & cleaning No knowledge Some knowledge Good knowledge Must score 2 before

discharge

Positioning for feed Depends on nurse Needs some help No help needed Must score 2 before discharge

Baby's ability to cup/ bottle feed Tube fed Cup and tube Takes all feeds well by cup /

bottle

Score here all babies

Socio-economic support No family help or support Occasional help / support Good support system Name support person:

Confidence in handling baby (changing/bathing) Always needs assistance Occasionally needs

assistance No help needed

Baby's weight gain / day 0 - 10 g/day 10 - 20 g/day 20 - 30 g/day Must score 1 or 2 for a few days

Confidence in giving of vitamin and iron drops No confidence Some confidence Fully confident

Mother's knowledge of KMC Little knowledge Some knowledge Knowledgeable

Acceptance & application of KMC Does not accept / apply Partially accepts or applies Fully accepts or applies Applies KMC on own

initiative

Confidence in caring for baby at home Does not feel sure / able Feels slightly sure / able Feels confident

Ready for discharge when the score is 19 or more Tota l

Adapted from Groote Schuur Hospital and Kalafong KMC Unit

PAGE ___


Name:________________________ Folder No:___________________

PAGE ___

KMC Daily Score Sheet Date

Date of birth: KMC start date: Day

Feeding choice: Breast / Formula PMTCT: yes / no Weight

Score 0 1 2 Intermittent (I)or Continuous (C) I/C

Breast fed Score here for exclusive breast feeding

Mom's milk production None Not enough Enough Must score 2 before discharge

Positioning at breast Needs help Some help needed No help needed

Baby's ability to suckle at breast Tube fed Breast AND cup or tube Mainly breast

Formula fed Score here for formula feeding Knowledge of formula preparation & cleaning No knowledge Some knowledge Good knowledge Must score 2 before

discharge

Positioning for feed Depends on nurse Needs some help No help needed Must score 2 before discharge

Baby's ability to cup/ bottle feed Tube fed Cup and tube Takes all feeds well by cup /

bottle

Score here all babies

Socio-economic support No family help or support Occasional help / support Good support system Name support person:

Confidence in handling baby (changing/bathing) Always needs assistance Occasionally needs

assistance No help needed

Baby's weight gain / day 0 - 10 g/day 10 - 20 g/day 20 - 30 g/day Must score 1 or 2 for a few days

Confidence in giving of vitamin and iron drops No confidence Some confidence Fully confident

Mother's knowledge of KMC Little knowledge Some knowledge Knowledgeable

Acceptance & application of KMC Does not accept / apply Partially accepts or applies Fully accepts or applies Applies KMC on own

initiative

Confidence in caring for baby at home Does not feel sure / able Feels slightly sure / able Feels confident

Ready for discharge when the score is 19 or more Tota l

Adapted from Groote Schuur Hospital and Kalafong KMC Unit


Date: Monitoring & handover sheet for neonatal transfers

(to be completed by referring and receiving doctors starting at time of referral) Time: MOTHER Baby’s Name: Baby’s Number: Birthweight (g)

Name:

Gender: ♂ / ♀ Address: Length (cm)

Folder Number:

Age: Grav: Para: Date of Birth (use sticker when available)

COH (cm)


Date VDRL/WR: ⊕ ⊖

Titre:1/ Rx X 3: ⓎⓃPCV/Hb

Blood Group: Antibodies: ⓎⓃTSB

Hypertension/PIH: ⓎⓃ Diabetes: ⓎⓃPhototherapy TB: ⓎⓃ Cardiac: ⓎⓃ

Epilepsy: ⓎⓃ APH: ⓎⓃ

Alcohol: ⓎⓃ Smoker: ⓎⓃ

Labour Induced: ⓎⓃ ROM: hrs

Con

tact

No

Con

tact

No

1st Stage: hrs 2nd Stage: mins

Pyrexia: ⓎⓃ AB’s: ⓎⓃ

Analgesia: ⓎⓃ Foetal distress: ⓎⓃ

BABY

Apgar:1min 5 min 10 minDes

igna

tion

Des

igna

tion

Resuscitation

MSL: ⓎⓃ SuctionedⓎⓃ

Action: None: ⓎⓃ Oxygen: ⓎⓃ

Mask ventilation: ⓎⓃ ETT+IPPV: ⓎⓃDoc

tor

Doc

tor

Drugs:


Plan

:

Plan

:

Plan

:

Plan

:

Plan

:

Plan

:

Plan

:

Cord pH: Cord BE:

Cord Blood

NO

NO

NO

NO

NO

NO

NO

Group: Coombs: ⊕ ⊖ WR: ⊕ ⊖Hos

pita

l

Hos

pita

l

Gestational Age Estimate: weeks

YE

S

YE

S

YE

S

YE

S

YE

S

YE

S

YE

S

US: weeks Scored: weeks

AGA UGA OGA

MTCT: Mother ⊕ /⊖ /? Breast / Formula Ref

errin

g:

Rec

eivi

ng:

Acc

epte

d

Acc

epte

d

Acc

epte

d

Acc

epte

d

Acc

epte

d

Acc

epte

d

Acc

epte

d


Antibiotic 1 Problem List

Antibiotic 2 #1:

% Oxygen Plan:

IPPV / CPAP

#2:

Plan:

Feed

s

IV (ml/hr) #3:

ml/kg/day Plan:

Age (day)

Once accepted for transfer, and transport arranged, continue overleaf


1) Ongoing monitoring and responsibility while awaiting EMRS Name Rank Contact number

Doctor

Nurse



O2 device

IV site secure

IV control device

IV rate AVPU BP Glucose Sign

On transfer

to ambulance

2) Problems arising while awaiting EMRS, and their plans Problem Plan Discussed with Verified by

3) Patient Transport information

Time accepted Receiving Hospital Doctor Rank Telephone Plan Sign

Time EMRS called EMRS Ops Centre Operator Designation Telephone Plan Sign

Time of EMRS arrival Ambulance type Paramedic Designation Telephone Plan Sign

Time at departure, AND receiving

hospital notified

Receiving Hospital Doctor Rank Telephone Plan Sign

Time of arrival at receiving hospital Receiving Ward Doctor Rank Telephone Plan Sign

4) Patient Handover

Handed over by Received by


Referring hospital to EMRS


5) Caregiver Plan

Name Relationship Contact number Breastfeeding Well/sick Plan for transport to receiving

hospital y/n

6) Outcome

Alive & not transferred

Died & not transferred

Died awaiting EMRS Died in transit Died within 24

hours of transfer Died beyond 24

hours of transfer

Alive and transferred back

to referring hospital

NB: this does not replace the usual referral letter containing ALL relevant clinical details: Use the ‘Neonatal Discharge/Referral Letter ’ proforma, and copy the ‘Newborn Care Record’


Page 1

Neonatal Discharge/Referral Letter MOTHER Baby’s Name: Baby’s Number: Gender:

♂ / ♀ Birth weight (g)

Name: Place of birth: Address: Length (cm)

Folder Number:

Age: Grav: Para: Date of birth: (use sticker when available)

COH (cm)


History, examination and management VDRL/WR: ⊕ ⊖

Titre:1/ Rx X 3: ⓎⓃ

Blood Group: Antibodies: ⓎⓃ

Hypertension/PIH: ⓎⓃ Diabetes: ⓎⓃ TB: ⓎⓃ Cardiac: ⓎⓃ Epilepsy: ⓎⓃ APH: ⓎⓃ Alcohol: ⓎⓃ Smoker: ⓎⓃ Labour Induced: �� ROM: hrs 1st Stage: hrs 2nd Stage: mins

Pyrexia: ⓎⓃ AB’s: ⓎⓃ Analgesia: ⓎⓃ Foetal distress: ⓎⓃ BABY

Apgar:1min 5 min 10 min

Resuscitation MSL: ⓎⓃ SuctionedⓎⓃ Action: None: ⓎⓃ Oxygen: ⓎⓃ

Mask ventilation: ⓎⓃ

ETT+IPPV: ⃞ ETT+IPPV: ⓎⓃ

Drugs:


Cord pH: Cord BE:

Cord Blood

Group: Coombs: ⊕ ⊖ WR: ⊕ ⊖ Gestational Age Estimate: weeks

US: weeks Scored: weeks

AGA UGA OGA

MTCT: Mother ⊕ /⊖ /? Breast / Formula


Problem List ICD 10

Feeding (type and amount) at discharge

Immunisations

Relevant investigation results

Investigation Date Result FBC U&E

Cultures TORCH screen

HIV Ultrasound head

Other

Prescription at discharge/referral (drug AND dose) 1 52 6 3 7 4 8 Futures plans and follow up arrangements

Problem Follow up date Follow up venue

PMTCT follow up (if applicable) PMTCT site: PMTCT date: Baby assessed for ARV’s: N/A Yes No Referred to ARV Clinic Mother assessed for ARV’s N/A Yes No Referred to ARV Clinic Remarks

The Road to Health Chart was updated and given to caregiver Yes No Not present Birth Registration was done Yes No Yours sincerely Sign:___________________________ Print/Stamp:________________________ Date: ____________ Contact number: _______________________________

Page 2


N E O N A T A L R E C O R D A U D I T DATE: ___________________________ HOSPITAL: ___________________________ DATE OF PATIENT’S ADMISSION: ___________________________ PATIENT’S DIAGNOSIS: ___________________________

Check each document for the following A. Patient’s details N/C P/C C COMMENTS Name and initials Hospital number

Ward

B. Name of consultant on patient’s notes

C. Documentation

1) Standardised Neonatal Record Keeping system used

2) Time of admission

3) Time of examination

4) Maternal ANC history

5) Maternal intrapartum history

6) Neonatal resuscitation details

7) PMTCT details (test, nevirapine, feeding choice)

8) Neonatal assessment details

9) Gestational age and anthropometry assessed and plotted

10) Medical examination with details of medical findings leading to diagnosis

11) Clear problem list

12) Clear plan for each problem

13) Request for special investigations

14) Results of special investigations in results sheet

15) Signature on all results of special investigations

16) Medication prescribed in notes & on prescription sheets

17) Feeds calculated and prescribed

18) Daily notes written using the problem oriented approach

19) Weight plotted correctly daily

20) Notes legible & in chronological order

21) Legible signature with pager no., date and time on every entry

22) Record of consultation with other paramedical services

Last modified: 15 June 2007 For review: 2009 2

N/C P/C C COMMENTS D. INFORMATION FOR PARENTS / CARE GIVER

1) Fully informed of findings & same documented

2) Parents participate in decision making relating to treatment and same documented

3) Informed consent for interventional procedures

E. DISCHARGE OF PATIENTS

1) Follow up plan recorded

2) Discharge medicines clearly prescribed (including dose)

3) Discharge summary/referral letter present in case sheet

4) RTHC filled in correctly and completely

GENERAL OVERVIEW / COMMENTS

1) Do patient’s records reflect high quality medical care?

2) Do records present a total picture of this patient?

3) Were other team members involved in the patients care and was this documented? e.g. Social Worker

4) Were hospital policies followed?

5) Was adequate Health Education given to parents during hospitalisation / on discharge

Auditors name: ___________________________ Signature: _______________________ Outcome of audit Reported by : ____________________________________ Reported to : ____________________________________ Date : ____________________________________ Rating: Non-compliant (n/c) = 0 Partially compliant (p/c) = 1 Compliant (c) = 2


Name:________________________ Folder No:___________________

Investigations Chemistry & Haematology

Date

Time

Renal Function Sodium

Potassium

Chloride

Bicarbonate

Urea

Creatinine

Liver Function Total Protein

Albumin

Total Bili/Conj Bili

ALP

GGT

ALT

LDH

INR

“CMP” Ca/Corrected

Magnesium

Phosphate

Haematology WCC

N%

L%

Hb

MCV

Platelets

Retics

PTT

Acid/Base & Blood Gasses Date

Time

FiO2

pH

pCO2

pO2

Base Excess

SBC

PAGE ___


Name:________________________ Folder No:___________________

Cultures

Date Test Result

Serology

Date Test Result

Radiology

Date Image

Other

Date Test Result

Test Date Age (Child) Result Child Exposed / Infected /

Not infected Caregiver informed

Mother Rapid

Mother Elisa

Child Rapid

Child ELISA

First PCR

First CD4

PAGE ___


Name:________________________ Folder No:___________________

Acid Base and Blood Gasses

Date Time Site FiO2 Sats Mode Vent Rate

Baby Rate IP/EP MAP TV IT pH pCO2 pO2 BE SBC Treatment Sign

PAGE ___


Name:________________________ Folder No:___________________

Oxygen Delivery and Saturation Monitoring Chart

Date Time

Face mask/ head

box FiO2 (%)

Face mask / head

box flow (l/min)

Nasal cath O2

flow (l/min)

Resp rate

(bpm)

Pulse rate

(bpm)

O2 saturation

(%)

Nebs

____ hrly Steps taken to get sats

normal Sign


Name: ____________________

Folder Number: ______________

Page ___

Hypoglycaemia Management Chart

Date Time Glucometer (mmol/l)

Action taken to get blood glucose normal

Next G’meter (time)

PRINT name


Name:________________________ Folder No:___________________

PAGE ___

Hourly Ventilator and CPAP Nursing Observations

Date Time FiO2 Sats (%) Pulse rate

Probe changed Humidifier full Water trap

empty ETT Secure Suction ___ hourly Saline lavage Secretions:

Amount Secretions: Appearance Sign


Name:________________________ Folder No:___________________

PAGE ___

Hourly Ventilator and CPAP Nursing Observations

Date Time FiO2 Sats (%) Pulse rate

Probe changed Humidifier full Water trap

empty ETT secure Suction ___ hourly Saline lavage Secretions:

Amount Secretions: Appearance Sign


Name:________________________ Folder No:___________________

PAGE ___

Intake Output Chart for Patients on Intravenous Fluids & Orals Age: _____ Weight: _____kg Date: ________________ Intravenous Intake Oral Intake Total in

Time Doctor’s Order Sign Time Doctor’s Order Sign Total out

Insensible loss

Balance

Output

Time Set Up

Type of fluid Amount Rate Time

Completed Subtotal/ carried Total Sign Time Type of

feed Amount How Given Sign Stool Vomit /

Aspirate Urine Other:

_______ Sign

08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00

To carry Total IV Total

oral Totals out


Name:________________________ Folder No:___________________

PAGE ___

Intake Output Chart for Patients on Intravenous Fluids & Orals Age: _____ Weight: _____kg Date:________________ Intravenous Intake Oral Intake Total in

Time Doctor’s Order Sign Time Doctor’s Order Sign Total out

Insensible loss

Balance

Output

Time Set Up

Type of fluid Amount Rate Time

Completed Subtotal/ carried Total Sign Time Type of

feed Amount How Given Sign Stool Vomit /

Aspirate Urine Other:

_______ Sign

08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00

To carry Total IV Total

oral Totals out


Name:________________________ Folder No:___________________

PAGE ___

Intake Output Chart for Patients on Orals Only Age: _____ Weight: _____kg Date:____________

Oral Intake Total in

Date Time Doctor’s Order Sign Total out

Insensible loss

Balance

Output

Time Type of feed Amount How Given Sign Stool Vomit Urine

Other: _______ Sign

If patient is on IV fluids, do not use this chart.


Name:________________________ Folder No:___________________

PAGE ___

Intake Output Chart for Patients on Orals Only Age: _____ Weight: _____kg Date:______________

Oral Intake Total in

Date Time Doctor’s Order Sign Total out

Insensible loss

Balance

Output

Time Type of feed Amount How Given Sign Stool Vomit Urine

Other: _______ Sign

If patient is on IV fluids, do not use this chart.


Letter in support of grant application

Institution: _____________________ Ward: ____________________ Date: ________________

To: The Welfare Officer Department of Welfare Dear Madam/Sir Re: Assistance with grant application Caregiver name: _____________________________ ID Number: ____________________________________

Child’s name: _____________________________ ID Number: ____________________________________

Kindly assist the bearer(s) with their social grant application(s). For processing the application, I have also asked the caregiver to be in possession of the indicated documentation:

Grant Eligibility criteria (circle applicable) Documents required

Old age pension ♂ > 65 years / ♀ > 60 years 1) Proof of income and assets of applicant and his/her

spouse

Child support grant

Household income: Urban < R800 pm; Rural/Informal < R1100 pm

1) Proof of income of primary care giver and his/her spouse

2) Proof that the applicant is the primary care giver of the child

Foster care grant De facto caregiver is not a parent; child must be placed in Foster Care by the Children’s Court

1) Proof of income of the foster child 2) Proof of regular school attendance 3) An order of the Children’s Court

Care dependency grant Child is severely handicapped

1) Proof of income of the applicant and his/her spouse as well as the child

2) Medical report in respect of the child

Social relief of distress Needs immediate help in order to survive

1) ID documents or birth certificates of all children 2) Proof of income and assets 3) Proof of efforts to get maintenance (letter from

Maintenance Court) 4) Proof that family has no money

In addition, I have advised that the following documents are required for ALL types of grant applications:

Document 13 digit barcode ID document of caregiver

Child’s birth certificate

Proof of caregiver’s marital status

On presentation of this letter to you, kindly supply the bearer with a receipt acknowledging the application, indicating the date of the application as well as your name, telephone number, and office.

Batho pele thanks

Sign: ___________________ Print Name: __________________ Stamp: ____________________

Contact number: ___________________