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? Ⓨ Ⓝ

Page 2

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:

Page 3 Clinical notes are continued on page 5

Date Abnormalities in Current Pregnancy and Labour Print name

Date Time First Contact Notes Print name

Page 4

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