Clinical Records: Complete Set - KwaZulu
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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 Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paediatrics Paed/C Paed/07 Paed/08 Paed/09 Paed/10 Paed/11 Paed/14 Paed/23 Paed/24 Paed/25 Paed/27 Paed/28 Paed/29 Paed/30 Paed/32 Paed/36 Paed/38 Paed/HIV1 Paed/A&D Slip Nursery Nursery Nursery Nursery Nursery Nursery Nursery Nursery Nursery Nursery Nursery Nursery Nursery Paed/A Paed/B Paed/01 Paed/02 Paed/03 Paed/04 Paed/05 Paed/06 Paed/26 Paed/31 Paed/34 Paed/37 Paed/39 Results Acid Base, Blood Gasses and Ventilator Settings Oxygen Delivery, Saturation and Nebs Monitoring Sheet Glucose Monitoring Sheet Ventilator & CPAP Observations Intake-Output: IV and Orals Intake-Output: Orals Only Letter in Support of Grant Application Both Both Both Both Both Both Both Both Paed/16 Paed/17 Paed/18 Paed/19 Paed/20 Paed/21 Paed/22 Paed/33 Catalogue Ordering Form Both Both Paed/D Paed/E Record Keeping Instructions: Children’s Ward Cover Page: Paediatric Patient Record (boys and girls) Admission Sheet Growth Chart: 0-36 months weight and length Growth Chart: 2-20 years weight and length Growth Chart: 0-36 months coh Gastro Continuation Sheet Paediatric Discharge/Referral Letter HIV Testing, Clinical Staging & Care Plan Rheumatic Heart Disease Prophylaxis Letter Brain Death Checklist Rheumatic Heart Disease Follow Up Record Monitoring Sheet for Paediatric Transfers Monitoring Sheet In-transit Burns Chart for Body Surface Area Children’s Coma Score Paediatric Record Audit ARV Appointment and Prescription Record Admission/Discharge Slip Record Keeping Instructions: Nursery Use of Infant Care Record Newborn Care Record (complete foldout) Weight and Intake Continuation Sheet: Neonate Clinical Notes Continuation Sheet: Neonate Growth Chart and Ballard Score: Neonate HIE Score: Neonate Basic Nursing Care: Neonate KMC Score Sheet Monitoring Sheet for Neonatal Transfers Jaundice Chart Neonatal Record Audit Neonatal Discharge/Referral Letter 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 By using these forms correctly, we will improve the quality of care our patients receive and we will save the hospital money, and we will save ourselves time and frustration 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 Cover Page: Paediatric Patient Record (boys and girls) Admission Sheet Growth Chart: 0-36 months weight and length Growth Chart: 2-20 years weight and length Growth Chart: 0-36 months coh Gastro Continuation Sheet Paediatric Discharge/Referral Letter HIV Testing, Clinical Staging & Care Plan Rheumatic Heart Disease Prophylaxis Letter Brain Death Checklist Rheumatic Heart Disease Follow Up Record Monitoring Sheet for Paediatric Transfers Monitoring Sheet In-transit Burns Chart for Body Surface Area Children’s Coma Score Paediatric Record Audit ARV Appointment and Prescription Record Admission/Discharge Slip Paed/C Paed/07 Paed/08 Paed/09 Paed/10 Paed/11 Paed/14 Paed/23 Paed/24 Paed/25 Paed/27 Paed/28 Paed/29 Paed/30 Paed/32 Paed/36 Paed/38 Paed/HIV1 Paed/A&D Slip Record Keeping Instructions: Nursery Use of Infant Care Record Newborn Care Record (complete foldout) Weight and Intake Continuation Sheet: Neonate Clinical Notes Continuation Sheet: Neonate Growth Chart and Ballard Score: Neonate HIE Score: Neonate Basic Nursing Care: Neonate KMC Score Sheet Monitoring Sheet for Neonatal Transfers Jaundice Chart Neonatal Record Audit Neonatal Discharge/Referral Letter Paed/A Paed/B Paed/01 Paed/02 Paed/03 Paed/04 Paed/05 Paed/06 Paed/26 Paed/31 Paed/34 Paed/37 Paed/39 Results Acid Base, Blood Gasses and Ventilator Settings Oxygen Delivery, Saturation and Nebs Monitoring Sheet Glucose Monitoring Sheet Ventilator & CPAP Observations Intake-Output: IV and Orals Intake-Output: Orals Only Letter in Support of Grant Application Paed/16 Paed/17 Paed/18 Paed/19 Paed/20 Paed/21 Paed/22 Paed/33 Catalogue Ordering Form Paed/D 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 By using these forms correctly, we will improve the quality of care our patients receive and we will save the hospital money, and we will save ourselves time and frustration Health: KwaZulu-Natal Form Reference number: Paed/C Clinical Records: Paediatrics Clinical Record Keeping: Paediatrics There is a standard structure for Paediatric Records, and for filing of non-current records. The Paediatric Patient Record is kept in the yellow “Outpatient Folder”. However, this is NOT an outpatient record. This is the patient clinical record that follows the patient throughout the institution, whenever and where ever the patient is seen. All Paediatric Patient Records are exactly the same (inside the yellow “outpatient” folder) Section 1) 2) 3) 4) 5) 6) 7) Cover page Growth chart: Birth to 36 months weight and height (boy chart facing) Growth chart: Birth to 36 months head circumference (boy chart facing) Growth chart: 2 to 18 years (boy chart facing) Results sheet HIV testing and staging sheet Continuation pages/History and Progress/Referral Letters Healthworker responsible Doctor Doctor Doctor Doctor Doctor Doctor Doctor The OPD clerks or nursing staff should assemble the “package” and bind them in the yellow folders. Continuation pages and referral letters must be bound chronologically. Special investigation reports (CT Scan, echo etc.) can be bound after the HIV sheet, or chronologically. The orderliness of the Paediatric Patient Record is the responsibility of the last doctor to make an entry. All Paediatric Inpatient Records are exactly the same (inside ward-based “Ring Binders”) All charts are in chronological order Section Temperature charts Doctor’s obs (results page, scoring sheets etc) Nursing obs (“routine”, ventilator, phototherapy, etc) Nursing Process Intake/Output/Feeds Prescription Road to health chart 1) 2) 3) 4) 5) 6) 7) 8) 9) Order Front to Back Front to Back Front to Back Back to Front Back to Front Back to Front Keep in a safe place and update when appropriate Non-current pages are removed after one-two days Results must be entered on results page, signed by attending doctor and filed away from the active record Each page should have patient’s name and inpatient 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 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 the department are standardised ALWAYS RECORD THE CHILD’S DATE OF BIRTH, IN ALL DESIGNATED PLACES “Gold Standard” folders should be developed for each unit, and used to refer to for structuring folders and to compare with during chart review meetings. 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: Date Gender: Male / Female Problem (enter significant problems only) (use sticker if available) ICD Code Management ICD Code Follow Up Place and Date Admissions Register DoA DoD Reason for Admission Name:________________________ Folder No:___________________ Background Information Perinatal History Antenatal Care: Delivery: Mother WR: + / - / ? Site: Mode: Gestation: Birthweight: Mother HIV: + / - / ? Place: Apgars: Length: COH: Problems: Not tested PMTCT: Mother Nevirapine: Y / N / ? Baby Nevirapine: Y / N / ? Follow up site for PCR/Cotrimoxazole/CD4: Vaccinations (insert date given, don’t tick) Vaccine 6 weeks 10 weeks At birth: 14 weeks 9 months BCG: Y / N Polio: Y / N 18 months Preschool Polio DTP Td HiB Hep B Measles Vitamin A Social History Primary caregiver: Name: Relationship: Household Income: Qualifies for Grant: Number of Dependents: CSG / CDG / FCG Caregiver advised: Y / N Nutrition: Referral letter given: Y / N 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) 2 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: Admitted from Admitting to DoA: Gender: m / f High care ICU Medical Discharged Outcome Surgical Transferred ToA: Admitting Doctor (print) Mixed Receiving Doctor (print) Absconded Died DoD: ToD: Name of hospital/clinic: Referred Ⓨ/Ⓝ/Ⓤ If yes, from: Another hospital A clinic Private sector If yes, from: Inside drainage area Outside drainage area Unknown Social Caregiver Alive and well Alive and well Mother Father Name: Unknown Telephone: Dead Sick Unknown Dead Sick Unknown Primary caregiver Mother Grandmother Father Other: _____ Nutrition OWFA Normal UWFA Marasmus Kwashiorkor M-K Unknown Weight: _____kg HIV / AIDS Laboratory test Clinical PMTCT st Feeding in 1 6 months Negative Exposed Stage I Stage II Not tested Not tested Unknown (but indicated) (not indicated) Not staged Not staged Stage III Stage IV Unknown (but indicated) (not indicated) Mother negative at Prophylaxis not given Unknown delivery Infected Prophylaxis given Exclusive breast for 6/12 No result No breast, ever Unknown Mixed, from birth 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) Narrow Breathing Needs IPPV Needs oxygen Hyperventilation Normal Circulation Shock (cap refill>3s) Hypovolaemia Hypervolaemia Normal Unconscious Response to Pain Response to Voice Alert In hospital Before arrival Past Never Oedema Consciousness (AVPU) Convulsions Dehydration 10% 5% IMCI classification “Red” “Yellow” SIRS (“toxic shock”) Needs IV agent Infection 2. Diagnostic workup (e.g. tuberculosis): 3. Social (e.g. poverty, distance, caregiver): 4. Specialist review/opinion: 5. Other: Normal Critical Airway Normal “Green” Needs oral agent No Health: KwaZulu-Natal Form Reference Number: Paed/08 Clinical Records: Paediatrics 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 blood glucose < 2.6 mmol/ l hypoglycaemia was / were given on: _______________ 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 Airway Breathing Circulation/Shock Dehydration Consciousness Infection Other Rx ETT: Bag/Mechanical IPPV: Oxygen: Continue on way to ward: Volume expand: Continue on way to ward: Rehydrate: Check Na: Protect airway: Coma position: IV antibiotic stat: Steroid/antipyretic: Initial investigations (tick for “done”, circle for “to do”) acid-base Chemistry 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 chest X-ray abdo X-ray CT Brain MRI U/S Echo Radiology 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 Nurse Weight Perfusion Doctor Respiratory rate Urine volume Acid-base Respiratory pattern Sats/O2 requirement Stools Heart rate Blood pressure Glucose Other: 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: ___________ 2 Time: ___________ 2007/06/21 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: Health: KwaZulu-Natal *Discharge Diagnosis: 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: Health: KwaZulu-Natal *Discharge Diagnosis: 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: 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 Nutrition status: 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 Birth to 36 months: Boys Length-for-age and Weight-for-age percentiles L E N G T H Birth in cm 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15 16 3 6 9 15 18 21 30 33 36 cm 100 75 95 50 25 90 10 3 in 41 40 39 38 37 36 35 L E N G T H 97 17 90 16 38 36 34 75 15 32 50 14 25 13 30 28 10 12 3 AGE (MONTHS) 7 12 15 Mother’s Stature Father’s Stature Date Age Birth 5 10 18 21 Weight 4 8 3 2 kg Birth 27 90 12 lb 24 97 6 6 RECORD # AGE (MONTHS) 14 W E I G H T 12 NAME 3 6 9 Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts 24 27 30 Gestational Age: Weeks Length Head Circ. 33 36 26 11 24 10 22 9 20 8 18 kg 16 lb Comment W E I G H T Birth to 36 months: Girls Length-for-age and Weight-for-age percentiles L E N G T H Birth in cm 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15 16 3 6 9 15 18 21 30 33 36 cm 100 75 95 50 25 90 10 in 41 40 39 38 37 36 35 L E N G T H 3 97 17 90 16 75 15 38 36 34 32 14 50 13 25 12 10 3 AGE (MONTHS) 7 12 15 Mother’s Stature Father’s Stature Date Age Birth 5 10 18 21 Weight 4 8 3 2 kg Birth 27 90 12 lb 24 97 6 6 RECORD # AGE (MONTHS) 14 W E I G H T 12 NAME 3 6 9 Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts 24 27 30 Gestational Age: Weeks Length Head Circ. 33 36 30 28 26 11 24 10 22 9 20 8 18 kg 16 lb Comment W E I G H T 2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles Mother’s Stature Date Father’s Stature Age Weight Stature BMI* NAME RECORD # 12 13 14 15 16 17 18 19 20 cm AGE (YEARS) 97 190 90 185 75 50 25 180 175 170 10 in 62 S T A T U R E 60 58 56 54 52 50 48 46 44 42 40 38 36 cm 3 4 5 6 7 8 9 10 11 3 165 160 160 155 155 150 150 74 72 70 68 66 64 62 60 140 105 230 135 97 100 220 130 125 90 95 210 90 200 120 85 115 80 75 75 110 105 50 100 25 95 10 90 3 190 180 170 160 70 150 W 65 140 E I 60 130 G 55 120 34 85 50 110 32 80 45 100 40 90 35 35 30 30 25 25 20 20 15 15 10 kg 10 kg 80 70 60 50 40 30 lb S T A T U R E 145 30 W E I G H T in 76 AGE (YEARS) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts 80 70 60 50 40 30 lb H T 2 to 20 years: Girls Stature-for-age and Weight-for-age percentiles Mother’s Stature Date Father’s Stature Age Weight Stature BMI* NAME RECORD # 12 13 14 15 16 17 18 19 20 cm AGE (YEARS) 190 185 180 97 175 90 170 75 in 62 S T A T U R E 60 58 56 54 52 50 48 46 44 42 40 38 cm 4 5 6 7 8 9 10 11 50 165 160 25 160 155 10 155 150 3 150 50 40 30 lb 66 S T A T U R E 64 62 60 100 220 130 95 210 90 200 125 97 120 85 115 80 110 90 75 190 180 170 160 70 105 75 100 95 85 60 68 135 34 70 70 105 230 50 150 W 65 140 E I 60 130 G 55 120 25 10 80 3 30 W E I G H T 72 140 90 80 74 145 36 32 3 in 76 50 110 45 100 40 90 35 35 30 30 25 25 20 20 15 15 10 kg 10 kg AGE (YEARS) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts 80 70 60 50 40 30 lb H T Birth to 36 months: Boys Head circumference-for-age and Weight-for-length percentiles in Birth cm 3 6 9 12 NAME RECORD # 15 18 21 24 27 30 33 cm AGE (MONTHS) 52 97 90 50 50 20 H E A D C I R C U M F E R E N C E 19 18 36 52 20 75 25 48 10 3 46 50 48 19 46 18 44 44 17 17 42 16 42 40 22 15 21 38 20 14 36 19 97 34 18 90 13 12 17 75 32 50 30 25 10 3 16 15 14 13 12 W E I G H T 24 22 20 18 16 14 14 12 10 8 6 4 2 lb in 11 11 10 10 9 9 8 8 7 7 6 6 5 5 kg LENGTH 4 3 2 1 kg cm 46 48 50 52 54 56 58 60 62 in 18 19 20 21 22 23 24 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Date Age Weight Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts Length Head Circ. cm in Comment H E A D C I R C U M F E R E N C E 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 lb W E I G H T Birth to 36 months: Girls Head circumference-for-age and Weight-for-length percentiles in Birth cm 3 6 9 12 NAME RECORD # 15 18 21 24 27 30 33 36 cm AGE (MONTHS) 52 in 52 97 20 90 50 H E A D C I R C U M F E R E N C E 19 18 75 50 48 25 10 46 3 20 50 48 19 46 18 44 44 17 17 42 16 42 40 22 15 21 38 20 14 36 97 34 90 13 18 17 75 16 32 12 19 50 15 25 10 3 30 14 13 12 W E I G H T 24 22 20 18 16 14 14 12 10 8 6 4 2 lb 11 11 10 10 9 9 8 8 7 7 6 6 5 5 kg LENGTH 4 3 2 1 kg cm 46 48 50 52 54 56 58 60 62 in 18 19 20 21 22 23 24 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Date Age Weight Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts Length Head Circ. cm in Comment H E A D C I R C U M F E R E N C E 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 lb W E I G H T Health: KwaZulu-Natal Form Reference Number: Paed/14 Clinical Records: Paediatrics Name: ____________________________ Folder no:_____________________ Progress notes for diarrhoeal disease Date: ___________________________ Time/Weight Intravascular vol Note: If ½DD, Ringer’s or formula is not appropriate, then delete and write in the alternative Time: Weight: Ⓝvol ↑vol Bolus O2 + fluid Rx Hydration Over Stools: no., type ↓vol / 5% ___ forming Nil + Drinking Eagerly poorly Calculation of fluid volumes and types needed (ml/24hrs) If NPO, give as: If taking orally, give as: Other Problems and plans / ____ ml = ____ ml/kg/hour Well Assessment ↑ _____ml Ringer’s Vomiting Urine output Weight: imminent arrest normal ___ normal Time: improving Bolus 10% Ⓜ ____ ml/kg/24 X wt hrs = ____ ml Ⓡ ____ ml/kg/24 hrs X wt = ____ ml Ⓛ ____ ml/kg/24 hrs X wt = ____ ml Over ___ normal ++ Nil Eagerly nil Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs ½ DD: ____ ml/hr 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 ↑ _____ml Ringer’s 5% ___ forming / Well ↔ Bolus 10% Over ↓ _____ml Ringer’s normal + ++ Nil + ++ poorly nil Eagerly poorly nil ____ ml/kg/24 X wt hrs = ____ ml Ⓡ ____ ml/kg/24 hrs X wt = ____ ml Ⓛ ____ ml/kg/24 hrs X wt = ____ ml Well As before Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs ½ DD: ____ ml/hr 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 / ____ ml = ____ ml/kg/hour ☺ Ⓜ ___ forming 10% ___ normal not monitored / 5% ___ watery ____ ml = ____ ml/kg/hour worse As before / Weight: ↓ normal ___ watery not monitored ISQ ↔ Time: ___ watery not monitored ☺ Ⓜ ____ ml/kg/24 X wt hrs = ____ ml Ⓡ ____ ml/kg/24 hrs X wt = ____ ml Ⓛ ____ ml/kg/24 hrs X wt = ____ ml As before Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs ½ DD: ____ ml/hr 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 Health: KwaZulu-Natal Form Reference Number: Paed/14 Clinical Records: Paediatrics Name: ____________________________ Folder no:_____________________ Progress notes for diarrhoeal disease Date: ___________________________ Time/Weight Intravascular vol Note: If ½DD, Ringer’s or formula is not appropriate, then delete and write in the alternative Time: Weight: Ⓝvol ↑vol Bolus O2 + fluid Rx Hydration Over Stools: no., type ↓vol / 5% ___ forming Nil + Drinking Eagerly poorly Calculation of fluid volumes and types needed (ml/24hrs) If NPO, give as: If taking orally, give as: Other Problems and plans / ____ ml = ____ ml/kg/hour Well Assessment ↑ _____ml Ringer’s Vomiting Urine output Weight: imminent arrest normal ___ normal Time: improving Bolus 10% Ⓜ ____ ml/kg/24 X wt hrs = ____ ml Ⓡ ____ ml/kg/24 hrs X wt = ____ ml Ⓛ ____ ml/kg/24 hrs X wt = ____ ml Over ___ normal ++ Nil Eagerly nil Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs ½ DD: ____ ml/hr 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 ↑ _____ml Ringer’s 5% ___ forming / Well ↔ Bolus 10% Over ↓ _____ml Ringer’s normal + ++ Nil + ++ poorly nil Eagerly poorly nil ____ ml/kg/24 X wt hrs = ____ ml Ⓡ ____ ml/kg/24 hrs X wt = ____ ml Ⓛ ____ ml/kg/24 hrs X wt = ____ ml Well As before Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs ½ DD: ____ ml/hr 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 / ____ ml = ____ ml/kg/hour ☺ Ⓜ ___ forming 10% ___ normal not monitored / 5% ___ watery ____ ml = ____ ml/kg/hour worse As before / Weight: ↓ normal ___ watery not monitored ISQ ↔ Time: ___ watery not monitored ☺ Ⓜ ____ ml/kg/24 X wt hrs = ____ ml Ⓡ ____ ml/kg/24 hrs X wt = ____ ml Ⓛ ____ ml/kg/24 hrs X wt = ____ ml As before Total ____ ml/kg/24 hrs X wt = ____ ml/24 hrs ½ DD: ____ ml/hr 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 Health: KwaZulu-Natal Form Reference Number: Paed/24 Clinical Records: Paediatrics 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 Health: KwaZulu-Natal Form Reference Number: Paed/24 Clinical Records: Paediatrics 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: 2 2007/06/08 Health: KwaZulu-Natal Form Reference Number: Paed/HIV1 Clinical Records: Paediatrics Name:____________________________ Folder Number:__________________ Appointment and prescription record for patients on ARV medicines Appointment 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 Date MO initials Pharm initials Weight + Height CD4 Viral Load Comment Health: KwaZulu-Natal Form Reference Number: Paed/HIV1 Clinical Records: Paediatrics Name:____________________________ Appointment Date MO initials Pharm initials Folder Number:__________________ Weight + Height 2 CD4 Viral Load Comment Health: KwaZulu-Natal Form Reference Number: Paed/25 Clinical Records: Paediatrics 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 Date Due Date Given Place Given (if oral used, also indicate date of issue and date of next collection) Signature INR 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: à >10 years Amoxicillin3 grams à <10 years Amoxicillin 1,5 grams Anaesthetic: à Penicillin or Amoxicillin equivalent Penicillin Allergic: à à <10 years Erythromycin 500 mg >10 years Erythromycin 1 gram Warfarin Dose Health: KwaZulu-Natal Form Reference Number: Paed/28 Clinical Records: Paediatrics 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 Health: KwaZulu-Natal Form Reference Number: Paed/36 Clinical Records: Paediatrics Children’s Coma Score Sheet: children under 4 years Name: ______________________ Folder Number: _________________ Date Time Eye opening Spontaneously To verbal stimuli To pain No eye response to pain 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 Best Motor Response Obeys verbal command or moves normally Localise pain or withdraws to touch Withdraws from pain Abnormal flexion to pain (decorticate) Abnormal extension to pain (decerebrate) No motor response to pain Best Verbal Response Alert; babbles; coos; usual words and sentences Less than usual ability and/or spontaneous irritable cry Cries inappropriately Occasionally whimpers and/or moans No verbal response to pain Total Suspected Phenobarb aetiology: Phenytoin Infection Benzodiazipine Trauma Opiate Seizures Thiopentone Toxin Other CVA Pulse Tumour Inborn error Other BP Respiratory rate Left Pupil Right pupil PTO for children 4 - 15 years Health: KwaZulu-Natal Form Reference Number: Paed/24 Clinical Records: Paediatrics Children’s Coma Score Sheet: children 4-15 years Name: ______________________ Folder Number: _________________ Date Time Eye opening Spontaneously To verbal stimuli To pain No eye response to pain 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 Best Motor Response Obeys verbal command Localise pain Withdraws from pain Abnormal flexion to pain (decorticate) Abnormal extension to pain (decerebrate) No motor response to pain Best Verbal Response Orientated and converses Disorientated and converses Inappropriate words Incomprehensible sounds No verbal response to pain Total Suspected aetiology: Infection Phenobarb Phenytoin Benzodiazipine Trauma Opiate Seizures Thiopentone Toxin Other CVA Pulse Tumour Inborn error Other BP Respiratory rate Left Pupil Right pupil PTO for children under 4 years Health: KwaZulu-Natal Form Reference Number: Paed/27 Clinical Records: Paediatrics Checklist for Documenting Brain Death Name:__________________________ Date of Birth:__________ I Folder No.:_________ 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 V Date&Time Isotope brain scan (if available) 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 Health: KwaZulu-Natal Form Reference Number: Paed/32 Name:________________________ Clinical Records: Paediatrics Folder No:___________________ Burns chart for assessing total body surface area burnt Use this chart on every child admitted with burns Date of burn: _____________ Date of assessment: _____________ Name (print): _____________ Agent: ________________ Time of burn: Time of assessment: Sign: ____________ ____________ ____________ Health: KwaZulu-Natal Form Reference Number: Paed/29 Clinical Records: Paediatrics Monitoring & handover sheet for paediatric transfers (to be completed by referring and receiving doctors starting at time of referral) Date: Patient Name: 1) Date of Birth: Time: DoA: DoT: REFERRING AND RECEIVING INFORMATION Hospital Ward Doctor Referring Designation Contact number Junior: Senior: Receiving Junior: Senior: 2) CAREGIVER INFORMATION Accompanying caregiver: 3) Normal UWFA Clinical M-K Exposed Infected No result Stage I Stage II Stage III Stage IV Current Ever CURRENT CONDITION (CIRCLE APPLICABLE) Vitals Unknown Weight: _____kg Not tested (but indicated) Not staged (but indicated) Never (but indicated) Not tested (not indicated) Not staged (not indicated) Never (not indicated) Unknown Unknown Unknown TIME: Temp: Airway PR: RR: Sats: Normal Critical Narrow Breathing Needs IPPV Needs oxygen Hyperventilation Normal Circulation Shock (Cap refill > 3s) Hypovolaemia Hypervolaemia Normal Unconscious Response to Pain Response to Voice Alert In hospital Before arrival Past Never Oedema Consciousness (AVPU) Convulsions Dehydration 10% 5% IMCI classification “Red” “Yellow” SIRS (“toxic shock”) Needs IV agent Infection Normal “Green” Needs oral agent No SIGNIFICANT BIOCHEMICAL PROBLEMS (CIRCLE APPLICABLE) Hypoxia (Sats in air____) 7) Kwashiorkor Negative ARV 6) Marasmus HIV Laboratory test 5) Contact number: NUTRITION OWFA 4) Relationship: Hypoglycaemia pH < 7.2 K+ < 2.0 K+> 6 Na+<120 Na+> 150 Albumin < 20 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) Airway Breathing Circulation/Shock Dehydration Consciousness Infection 9) Other Rx ETT / oral airway / none Oxygen delivery: IPPV / Bag / Spontaneous Oxygen monitoring: Intra-osseous / peripheral IV / central IV / none Volume expand: IV / Oral ½ DD / ORS: Protect airway: Coma position: IV antibiotic stat: Steroid / antipyretic: PAIN ASSESSMENT No pain Analgesia plan: Mild pain Moderate pain Severe pain Health: KwaZulu-Natal Form Reference Number: Paed/08 Clinical Records: Paediatrics 10) ONGOING MONITORING AND RESPONSIBILITY WHILE AWAITING EMRS Name Rank Contact number Doctor Nurse Time Heart rate Temp Resp rate Sats O2 device Fi O2 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 Time Handover Point Name Received by 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 2 2007/06/26 Health: KwaZulu-Natal Form Reference Number: Paed/30 Clinical Records: Paediatrics 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 Referring Designation Contact number Junior: Senior: Junior: Receiving 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 Time Heart rate Temp Resp rate Sats Fi O2 O2 device IV site secure IV control device IV rate GCS BP Glucos e 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 Time Handover Point Name Designation Received by Name Designation Sign EMRS to receiving hospital If further recording is required, or if problems were encountered, use space overleaf Health: KwaZulu-Natal Form Reference Number: Paed/08 Clinical Records: Paediatrics Notes: Problems encountered with the actual transfer: Plan for reporting problems: 2 2007/06/08 Health: KwaZulu-Natal Form Reference Number: Paed/23 Clinical Records: Paediatrics Paediatric Discharge/Referral Letter Hospital: Date: Patient Name: Date of Birth: DOA: Address: Gender: Male / Female DOD: OP Number: Ward: IP Number: Doctor in charge: Referred by: Healthworker Clinic Alive Dead Hospital Age: Private Practice Self Name: Outcome: Transferred to another hospital: Dear Colleague Thank you for receiving the above-named patient. The child was found to have the following problems: ICD Code 1 (main diagnosis) ICD Code 4 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 Age (Child) Date Child Exposed / Infected / Not infected Result Caregiver informed (date) Mother’s serology Child’s serology Initial PCR Current CD4 ART Started Clinical stage Tuberculosis 1 Contact: 2 Skin test: 3 CXR: 4 Rx started: Vaccinations Up to Date Incomplete → action taken: Social History Qualifies for Grant: CSG / CDG / FCG Family History Development Normal Delayed → action taken: Past Medical History Caregiver advised: Y / N Letter given: Y / N Not staged 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: ______________________ 2 2007/06/26 Health: KwaZulu-Natal Form Reference Number: Paed/38 Clinical Records: Paediatrics PA E D I AT R I C R E CO R D AU 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: 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 N/C P/C C COMMENTS D. INFORMATION FOR PARENTS / CARE GIVER 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 N/C P/C C COMMENTS 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) Partially compliant (p/c) Compliant (c) Last modified: 15 June 2007 = = = 0 1 2 2 For review: 2007 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 ¾ 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. 2. 3. 4. 5. Insert the referral letter here if there is one Details of abnormalities during pregnancy, labour and or/delivery to be documented in the space provided Clinical “First Contact” notes start below this. Doctors AND nurses can use the same pages for clinical notes List the significant problems on the front page as well 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 Baby’s Name: Gender: ♂ Form reference number: Paed/01 Baby’s Number: /♀ Birthweight (g) Address: Length (cm) Date of Birth: COH (cm) (use sticker when available) Time of birth NVD Breech Assisted C/S Clinical Records: Paediatrics MOTHER Name: Folder Number: Age: Grav: Para: Received ANC: ⓎⓃ Pregnancy LMP (mm/yy)/ EDD / Date VDRL/WR: ⊕ ⊖ Titre:1/ Rx X 3: ⓎⓃ Blood Group: Antibodies: ⓎⓃ Hypertension/PIH: ⓎⓃ Diabetes: ⓎⓃ TB: ⓎⓃ Cardiac: ⓎⓃ Epilepsy: ⓎⓃ APH: ⓎⓃ Alcohol: ⓎⓃ Smoker: ⓎⓃ 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 Labour ROM: hrs Induced: 1 Stage: hrs 2 Stage: mins st 39 nd Pyrexia: ⓎⓃ AB’s: ⓎⓃ Analgesia: ⓎⓃ Foetal distress: ⓎⓃ BABY Apgar:1min 5 min 10 min Resuscitation 38 MSL: ⓎⓃ None: ⓎⓃ Oxygen: ⓎⓃ Mask ventilation: ⓎⓃ ETT+IPPV: ⓎⓃ Action: 37 SuctionedⓎⓃ Drugs: TSR: (mins) ‘Distress’ Indicators: Cord pH: Cord BE: Cord Blood 36 Group: Coombs: ⊕ ⊖ Estimate: weeks Gestational Age US: weeks 35 AGA WR: ⊕ ⊖ Scored: weeks UGA MTCT: Mother ⊕ /⊖ /? OGA Breast / Formula Mother NVP: Ⓨ/Ⓝ/?/na Baby NVP: Ⓨ/Ⓝ/?/na Problem List ICD 34 Antibiotic 1 Antibiotic 2 % Oxygen IPPV / CPAP Feeds Other: Birth Attendant IV (ml/hr) Print: Sign: ml/kg/day Age (day) Put to breast in LW? Page 1 ⓎⓃ First Examination (mark the appropriate block) Previous Pregnancy Appearance Well Sick Dysmorphic Temperature 36-37 °C Hypothermic Hyperthermic 1. Well nourished Obese Wasted 2. Normal Offensive Responsive Lethargic Irritable Jittery Pink Blue Plethoric Pale 120-160 /min Tachycardia Bradycardia Murmur Nutrition Odour Behaviour Colour Apex bpm Year Abnormalities 3. 4. Jaundice 5. Placenta Normal Wide-spaced Engorged Discharging 40-60 /min Fast Slow Irregular Symmetrical Asymmetrical Shallow Clots: Absent Costal Sternal Number of Cord vessels: Quiet Grunting Noisy Abdomen Normal Distended Scaphoid Large liver Large spleen Recorded by (print): Umbilicus Normal Moist Flare Bleeding Mec. stained Vitamin K given Site Date: Hydrocoele Inguinal hernia Hypospadias Print name: Sign: Breast/Nipples Resp. rate Chest movement Recession Breath sounds Accessory Weight: Appearance: Cord knots: Femoral pulses Present Absent Genitalia: Male Testes down Undescended Genitalia: Female Normal Ambiguous Eye prophylaxis given Date: Urine Passed Not passed Print name: Sign: Anus Patent Imperforate Meconium Passed Not passed Identification Date: At Birth 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 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 Intact Clavicles (or) Mother’s Thumbprint Absent Fracture Nursery Date 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 Nose Patent Blocked Eyes Normal Small Large Ears Normal Abnormal Low position Neck Normal Swellings Webbed Back Normal Meningocoele Head shape Normal Asymmetrical Fontanelles Normal Bulging Sutures Mobile Overriding Muscle tone Abnormal (or) Mother’s Thumbprint Slanting Infected Sacral dimple Hair tuft Scoliosis Caput Haematoma Trauma Large Third Sunken Widened Fused Normal Hypotonic Hypertonic Skin Intact Bruising Rash Purpura Cry Normal Hoarse High-pitched Weak Assessment: Assessed by (print name): Sign: Date: Time: Page 2 Absent Footprint Date Date Abnormalities in Current Pregnancy and Labour Time First Contact Notes Page 3 Print name Print name Clinical notes are continued on page 5 Apgar Scoring Chart (circle appropriate number, an accurate score is essential) Assessment None Less than 100 More than 100 Absent Weak/Irregular Good/Cries Central Cyanosis Peripheral Cyanosis Peripherally Pink Limp Some Flexion Active/Well Flexed None Some Response Good Response Total Score Heart rate Respiration Colour Tone Response to stimulation Scored by: Print name 1 Minute 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 /10 Sign 5 Minutes 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 /10 10 Minutes 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 /10 Date Pre-discharge Checklist Checked by: Pint Name: Health Education given: RTHC filled in y n Sign: Feeding well Eyes normal Cord infection Meconium passed BCG given Buttock care Cord care RTHC instruction y y y y y y y y Date: n n n n n n n n Breast fed Jaundice Cord stump normal Urine passed Polio given Infant feeding General hygiene Birth registration done Unresolved problems at discharge y y y y y y y y n n n n n n n n 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 4 Health: KwaZulu-Natal Form Reference number: Paed/02 Clinical Records: Paediatrics Fold page to ascertain centre for punching holes prior to cutting Write 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 Feeds IPPV / CPAP IV (ml/hr) ml/kg/day Age (day) Page _____ ⇓ Health: KwaZulu-Natal Form Reference number: Paed/03 Name: __________________________ Date&Time Problem Clinical Records: Paediatrics Folder Number: _______________________ Clinical Notes PAGE _____ Investigation Management Health: KwaZulu-Natal Form Reference number: Paed/03 Name: __________________________ Date&Time Problem Clinical Records: Paediatrics Folder Number: _______________________ Clinical Notes PAGE _____ Investigation Management Health: KwaZulu-Natal Form Reference number: Paed/04 Name: ______________________________ Clinical Records: Paediatrics 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, Breast Imperceptible Barely perceptible Flat areola, no 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 Genitals, male Scrotum flat, smooth Scrotum empty, faint rugae Testes in upper cannal, rare rugae Testes descending, few rugae Prominent clitoris, small labia minora Prominent clitoris, enlarging minora Majora and minora equally prominent Genitals, Clitoris prominent, female labia flat Anterior Heel-toe >50 Creases over Faint red marks transverse crease mm, no creases anterior 2/3 only Creases over entire sole Stippled areola, 1- Raised areola, Full areola, 5-10 2 mm bud 3-4 mm bud mm bud Formed and firm, with instant recoil Thick cartilage, ear stiff Testes Testes down, pendulous, deep good rugae rugae Majora large, minora small Majora cover clitoris and minora Physical Score: ________ Neuromuscular Maturity 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. Neuromuscular Score: _______ Total Score: _______ Maturity Rating: _______ Total Score -10 -5 0 5 10 15 20 25 30 35 40 45 50 Gestational Age, Weeks 20 22 24 26 28 30 32 34 36 38 40 42 44 Plot weight on the growth chart overleaf, then decide on: OGA (overweight for gestational age) Last modified: 08 June 2007 AGA (appropriate for gestational age) UGA (underweight for gestational age) For review: 2009 Health: KwaZulu-Natal Last modified: 08 June 2007 Form Reference number: Paed/04 Clinical Records: Paediatrics For review: 2009 Health: KwaZulu-Natal Form Reference number: Paed/05 Clinical Records: Paediatrics Hypoxic Ischaemic Encephalopathy Score Sheet Name: ______________________ Folder Number: _________________ Date of Birth: _______________ Score Date 1 Sign 0 1 2 3 Tone Normal Hyper Hypo Flaccid LOC Normal Staring Lethargic Comatose Fits None <3/day >2/day Posture Normal Fisting Frog-like Moro Normal Partial Absent Grasp Normal Poor Absent Suck Normal Poor Absent +/-bites Respiration Normal Hyper Apnoea Fontanelle Normal Full Tense Comment on labour, delivery, resuscitation Decerebrate IPPV Total Phenobarb Magnesium Clonazepam Midazolam Valium Other 2 3 4 5 6 7 8 9 10 11 12 13 14 Health: KwaZulu-Natal Form Reference Number: Paed/34 Clinical Records: Paediatrics 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 Use “Exchange Transfusion” chart overleaf if EXCHANGE TRANSFUSION is a possibility PHOTOTHERAPY WESTERN 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 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 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. 340 320 300 Micro mol / L TSB (total serum bilirubin) 280 260 240 220 200 180 160 140 120 X X X X 100 X 80 60 40 20 0 X 6h 12h 24h 36h 48h X X X X 38+ wks or 3000+g 35 – 37w6d or 2500 – 2999g 34 – 34w6d or 2000 – 2499g 32 – 33w6d or 1500 – 1999g 30 – 31w6d or 1250 – 1499g 28 – 29w6d or 1000 – 1249g <28w or <1000g 60h 72h 84h 96h 108h 120h Time (age of baby in hours) Start intensive phototherapy when the TSB is ≥ the line according according to gestation or weight. Name:________________________ Folder No:___________________ Neonatal Jaundice Monitoring Chart: Exchange Transfusion EXCHANGE TRANSFUSION WESTERN 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 Micro mol / L TSB (total serum bilirubin) 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 450 440 430 420 410 400 390 380 X 370 360 350 340 330 320 310 300 290 280 270 260 250 240 230 220 210 200 190 180 38+ wks or 3000+g 35 – 37w6d or 2500 – 2999g 34 – 34w6d or 2000 – 2499g 32 – 33w6d or 1500 – 1999g 30 – 31w6d or 1250 – 1499g 28 – 29w6d or 1000 – 1249g <28w or <1000g X X X X X X X X X X 6h 12h 24h 36h 48h 60h 72h 84h 96h 108h Time (age of baby in hours) 120h Record all TSB’s, Hb/PCV’s, phototherapy, baby’s group and Coomb’s, and mother’s group in the designated places on the “Newborn Care Record” (Form Paed/01) 2 Health: KwaZulu-Natal Form Reference number: Paed/06 Clinical Records: Paediatrics 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 * If baby’s glucose is less than 2.5mmol/l, use hypoglycaemia monitoring sheet ** If baby is on oxygen, use oxygen monitoring sheet PAGE ___ 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 Health: KwaZulu-Natal Form Reference number: Paed/06 Clinical Records: Paediatrics 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 * If baby’s glucose is less than 2.5mmol/l, use hypoglycaemia monitoring sheet ** If baby is on oxygen, use oxygen monitoring sheet PAGE ___ 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 Health: KwaZulu-Natal Form Reference Number: Paed/26 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ KMC Daily Score Sheet Date Date of birth: KMC start date: Feeding choice: Breast / Formula Score PMTCT: yes / no 0 Breast fed Day 1 Weight 2 Intermittent (I)or Continuous (C) Must score 2 before discharge I/C Score here for exclusive breast feeding Mom's milk production None Not enough Enough Positioning at breast Needs help Some help needed No help needed Tube fed Breast AND cup or tube Mainly breast Baby's ability to suckle at breast Formula fed Knowledge of formula preparation & cleaning Score here for formula feeding 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 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 Confidence in giving of vitamin and iron drops No confidence Some confidence Fully confident Mother's knowledge of KMC Little knowledge Some knowledge Knowledgeable Does not accept / apply Partially accepts or applies Fully accepts or applies Does not feel sure / able Feels slightly sure / able Feels confident Acceptance & application of KMC Confidence in caring for baby at home Ready for discharge when the score is 19 or more Name support person: Must score 1 or 2 for a few days Applies KMC on own initiative Total Adapted from Groote Schuur Hospital and Kalafong KMC Unit PAGE ___ Health: KwaZulu-Natal Form Reference Number: Paed/26 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ KMC Daily Score Sheet Date Date of birth: KMC start date: Feeding choice: Breast / Formula Score PMTCT: 0 Breast fed Day yes / no 1 Weight 2 Intermittent (I)or Continuous (C) Must score 2 before discharge I/C Score here for exclusive breast feeding Mom's milk production None Not enough Enough Positioning at breast Needs help Some help needed No help needed Tube fed Breast AND cup or tube Mainly breast Baby's ability to suckle at breast Formula fed Knowledge of formula preparation & cleaning Score here for formula feeding 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 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 Confidence in giving of vitamin and iron drops No confidence Some confidence Fully confident Mother's knowledge of KMC Little knowledge Some knowledge Knowledgeable Does not accept / apply Partially accepts or applies Fully accepts or applies Does not feel sure / able Feels slightly sure / able Feels confident Acceptance & application of KMC Confidence in caring for baby at home Ready for discharge when the score is 19 or more Name support person: Must score 1 or 2 for a few days Applies KMC on own initiative Total Adapted from Groote Schuur Hospital and Kalafong KMC Unit PAGE ___ Health: KwaZulu-Natal Form reference number: Paed/31 Clinical Records: Paediatrics Monitoring & handover sheet for neonatal transfers (to be completed by referring and receiving doctors starting at time of referral) Date: Baby’s Name: Baby’s Number: Birthweight (g) Time: MOTHER Name: Gender: ♂ /♀ Address: Length (cm) Folder Number: Date of Birth COH (cm) Age: (use sticker when available) Time of birth NVD Breech Assisted Grav: LMP (mm/yy)/ EDD / VDRL/WR: ⊕ ⊖ Date Titre:1/ Rx X 3: ⓎⓃ Blood Group: Antibodies: ⓎⓃ Hypertension/PIH: ⓎⓃ Diabetes: ⓎⓃ TB: ⓎⓃ Cardiac: ⓎⓃ Epilepsy: ⓎⓃ APH: ⓎⓃ Alcohol: ⓎⓃ Smoker: ⓎⓃ PCV/Hb TSB Contact No Contact No Phototherapy ROM: hrs Labour Induced: ⓎⓃ 1 Stage: hrs 2 Stage: mins Designation st Designation Received ANC: ⓎⓃ Pregnancy C/S Para: nd Pyrexia: ⓎⓃ AB’s: ⓎⓃ Analgesia: ⓎⓃ Foetal distress: ⓎⓃ BABY Apgar:1min 5 min 10 min Doctor Doctor Resuscitation MSL: ⓎⓃ SuctionedⓎⓃ None: ⓎⓃ Oxygen: ⓎⓃ Mask ventilation: ⓎⓃ ETT+IPPV: ⓎⓃ Action: Plan: Plan: Plan: Plan: Plan: Plan: Plan: TSR: (mins) ‘Distress’ Indicators: Cord pH: Cord BE: NO YES Group: Gestational Age Accepted NO YES Accepted NO YES Accepted NO YES Accepted NO YES Accepted NO YES Accepted YES NO Cord Blood Accepted Hospital Receiving: Referring: Hospital Drugs: AGA OGA Breast / Formula Mother NVP: Ⓨ/Ⓝ/?/na Baby NVP: Ⓨ/Ⓝ/?/na Problem List #1: % Oxygen Plan: IPPV / CPAP #2: Feeds Scored: weeks UGA MTCT: Mother ⊕ /⊖ /? Antibiotic 2 Plan: IV (ml/hr) #3: ml/kg/day Plan: Once accepted for transfer, and transport arranged, continue overleaf WR: ⊕ ⊖ Estimate: weeks US: weeks Antibiotic 1 Age (day) Coombs: ⊕ ⊖ Health: KwaZulu-Natal 1) Form reference number: Paed/31 Clinical Records: Paediatrics Ongoing monitoring and responsibility while awaiting EMRS Name Rank Contact number Doctor Nurse Time Heart rate Temp Resp rate Sats Fi O2 O2 device IV site secure IV control device IV rate AVPU BP Glucos e Sign On transfer to ambulance 2) Problems arising while awaiting EMRS, and their plans Problem 3) Plan Discussed with Verified by 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 Time Handover Point Name Received by Designation Name Designation Sign Referring hospital to EMRS EMRS to receiving hospital 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 Alive and transferred back Died in transit 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’ Died awaiting EMRS Died within 24 hours of transfer Died beyond 24 hours of transfer Health: KwaZulu-Natal Form reference number: Paed/39 Clinical Records: Paediatrics Neonatal Discharge/Referral Letter Baby’s Name: Baby’s Number: Place of birth: Address: Gender: ♂/♀ Date of birth: Birth weight (g) Length (cm) COH (cm) (use sticker when available) Time of birth NVD Breech Assisted C/S MOTHER Name: Folder Number: Age: Grav: Para: Received ANC: ⓎⓃ Pregnancy LMP (mm/yy)/ EDD / VDRL/WR: ⊕ ⊖ History, examination and management Titre:1/ Rx X 3: ⓎⓃ Blood Group: Antibodies: ⓎⓃ Hypertension/PIH: ⓎⓃ Diabetes: ⓎⓃ TB: ⓎⓃ Cardiac: ⓎⓃ Epilepsy: ⓎⓃ APH: ⓎⓃ Alcohol: ⓎⓃ Smoker: ⓎⓃ Labour ROM: hrs Induced: 1 Stage: hrs 2 Stage: mins st nd Pyrexia: ⓎⓃ AB’s: ⓎⓃ Analgesia: ⓎⓃ Foetal distress: ⓎⓃ BABY Apgar:1min 5 min 10 min Resuscitation Action: MSL: ⓎⓃ SuctionedⓎⓃ None: ⓎⓃ Oxygen: ⓎⓃ Mask ventilation: ⓎⓃ ETT+IPPV: ETT+IPPV: ⓎⓃ ⃞ Drugs: TSR: (mins) ‘Distress’ Indicators: Cord pH: Cord BE: Cord Blood Group: Coombs: ⊕ ⊖ Estimate: weeks Gestational Age US: weeks AGA WR: ⊕ ⊖ UGA MTCT: Mother ⊕ /⊖ /? Scored: weeks OGA Breast / Formula Mother NVP: Ⓨ/Ⓝ/?/na Baby NVP: Ⓨ/Ⓝ/?/na Problem List ICD 10 Page 1 Feeding (type and amount) at discharge Immunisations Relevant investigation results Investigation FBC U&E Cultures TORCH screen HIV Ultrasound head Other Date Result Prescription at discharge/referral (drug AND dose) 1 2 3 4 Futures plans and follow up arrangements Problem PMTCT follow up (if applicable) PMTCT site: Baby assessed for ARV’s: Mother assessed for ARV’s N/A N/A 5 6 7 8 Follow up date PMTCT date: Yes Yes Follow up venue No No Referred to ARV Clinic Referred to ARV Clinic Remarks The Road to Health Chart was updated and given to caregiver Yes No Birth Registration was done Yes No Not present Yours sincerely Sign:___________________________ Print/Stamp:________________________ Contact number: _______________________________ Page 2 Date: ____________ Health: KwaZulu-Natal Form Reference Number: Paed/37 Clinical Records: Paediatrics N E O N ATA L R E CO 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 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 N/C P/C C COMMENTS 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) Partially compliant (p/c) Compliant (c) Last modified: 15 June 2007 = = = 0 1 2 2 For review: 2009 Health: KwaZulu-Natal Form Reference Number: Paed/16 Name:________________________ Clinical Records: Paediatrics 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 ___ Health: KwaZulu-Natal Form Reference Number: Paed/16 Name:________________________ Clinical Records: Paediatrics Folder No:___________________ Cultures Date Test Result Test Result Serology Date Radiology Date Image Date Test Other Test Date Age (Child) Result Result Mother Rapid Mother Elisa Child Rapid Child ELISA First PCR First CD4 PAGE ___ Child Exposed / Infected / Not infected Caregiver informed Form reference number: Paed/17 Health: KwaZulu-Natal Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Acid Base and Blood Gasses Date Time Site FiO2 Sats Mode Vent Rate Baby Rate IP/EP MAP TV IT PAGE ___ pH pCO2 pO2 BE SBC Treatment Sign Form reference number: Paed/17 Health: KwaZulu-Natal Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Acid Base and Blood Gasses Date Time Site FiO2 Sats Mode Vent Rate Baby Rate IP/EP MAP TV IT PAGE ___ pH pCO2 pO2 BE SBC Treatment Sign Health: KwaZulu-Natal Form Reference Number: Paed/18 Name:________________________ Clinical Records: Paediatrics 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 Health: KwaZulu-Natal Form Reference Number: Paed/18 Name:________________________ Clinical Records: Paediatrics 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 Health: KwaZulu-Natal Form Reference number: Paed/19 Name: ____________________ Clinical Records: Paediatrics Folder Number: ______________ Hypoglycaemia Management Chart Date Time Glucometer (mmol/l) Action taken to get blood glucose normal Page ___ Next G’meter (time) PRINT name Health: KwaZulu-Natal Form Reference number: Paed/19 Name: ____________________ Clinical Records: Paediatrics Folder Number: ______________ Hypoglycaemia Management Chart Date Time Glucometer (mmol/l) Action taken to get blood glucose normal Page ___ Next G’meter (time) PRINT name Health: KwaZulu-Natal Form Reference Number: Paed/20 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Hourly Ventilator and CPAP Nursing Observations Date Time FiO2 Sats (%) Pulse rate Probe changed Humidifier full Water trap empty ETT Secure PAGE ___ Suction ___ hourly Saline lavage Secretions: Amount Secretions: Appearance Sign Health: KwaZulu-Natal Form Reference Number: Paed/20 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Hourly Ventilator and CPAP Nursing Observations Date Time FiO2 Sats (%) Pulse rate Probe changed Humidifier full Water trap empty ETT secure PAGE ___ Suction ___ hourly Saline lavage Secretions: Amount Secretions: Appearance Sign Health: KwaZulu-Natal Form Reference Number: Paed/21 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Intake Output Chart for Patients on Intravenous Fluids & Orals Age: _____ Intravenous Intake Oral Intake Doctor’s Order Time Weight: _____kg Sign Total in Doctor’s Order Time Date: ________________ 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 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 PAGE ___ Totals out Vomit / Aspirate Urine Other: _______ Sign Health: KwaZulu-Natal Form Reference Number: Paed/21 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Intake Output Chart for Patients on Intravenous Fluids & Orals Age: _____ Intravenous Intake Date:________________ Oral Intake Doctor’s Order Time Weight: _____kg Sign Total in Doctor’s Order Time 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 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 PAGE ___ Totals out Vomit / Aspirate Urine Other: _______ Sign Health: KwaZulu-Natal Form Reference Number: Paed/22 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Intake Output Chart for Patients on Orals Only Age: _____ Oral Intake Date Time Weight: _____kg Date:____________ Total in 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. PAGE ___ Health: KwaZulu-Natal Form Reference Number: Paed/22 Clinical Records: Paediatrics Name:________________________ Folder No:___________________ Intake Output Chart for Patients on Orals Only Age: _____ Oral Intake Date Time Weight: _____kg Date:______________ Total in 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. PAGE ___ Health: KwaZulu-Natal Form Reference Number: Paed/33 Clinical Records: Paediatrics Letter in support of grant application Institution: _____________________ To: Ward: ____________________ Date: ________________ The Welfare Officer Department of Welfare Dear Madam/Sir Re: Assistance with grant application Caregiver name: Child’s name: _____________________________ _____________________________ ID Number: ____________________________________ 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: 9 Grant Old age pension Eligibility criteria (circle applicable) ♂ > 65 years / ♀ > 60 years Child support grant Household income: Urban < R800 pm; Rural/Informal < R1100 pm Foster care grant De facto caregiver is not a parent; child must be placed in Foster Care by the Children’s Court Care dependency grant Child is severely handicapped Social relief of distress Needs immediate help in order to survive Documents required 1) Proof of income and assets of applicant and his/her spouse 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 1) Proof of income of the foster child 2) Proof of regular school attendance 3) An order of the Children’s Court 1) Proof of income of the applicant and his/her spouse as well as the child 2) Medical report in respect of the child 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: 9 9 9 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: __________________ Contact number: ___________________ Stamp: ____________________
