Admission | In-hospital Follow-up | Outcome | |
Demographics | Initial Presentation/Evaluation | Patient location (ward) | Date of outcome |
Admission date and time Patient name Guardian name and phonenumber (if available) Age of patient (in months) Date of birth (if known) Gender Place and district of residence | Blantyre coma score Capillary refill Presence or absence of convulsions, respiratory distress, and oedema Vital signs Nutritional status (weight, height, middle upper arm circumference (MUAC)) Labs ordered and resulted (haemoglobin, malaria rapid diagnostic test, random blood sugar) Respiratory support (if needed) Consults ordered Treatments administered | Labs ordered Labs resulted Results for select labs (malaria rapid diagnostic test, haemoglobin, HIV testing) If haemoglobin is <6 g/dL, was blood transfusion ordered? If blood transfusion was ordered, was it given? Consults ordered Consults completed Radiology studies ordered Radiology studies completed Any surgeries performed | Patient disposition (discharge home, absconded, death, unknown) If patient died, date and time of death Discharge diagnoses Treatments ordered at discharge Follow-up appointments, if recommended Consults ordered Consults completed Radiology studies ordered Radiology studies completed Any surgeries performed |
Patient History | |||
Past medical history Chronic medications Immunisation status HIV status including treatment and date of diagnosis if positive Referral facility and date (if referred) Pre-referral management (if referred) including labs, blood transfusions, and treatments Traditional medicine use prior to admission | |||
Admission Details | |||
Admission diagnoses Admission ward |