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PATIENT ID NUMBER: KT       

 

WARD #*: ________     BED # _____ * BEGIN NEW FORM WHEN MOVED TO NEW WARD

Time (24 hr)

Date: DD/MM

__ __ : __ __

__ __ / __ __

__ __ : __ __

__ __ / __ __

__ __ : __ __

__ __ / __ __

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Provider (your) name

 

 

 

 

 

CURRENT Consciousness

A     V     P     U

A     V     P     U

A     V     P     U

A     V     P     U

Temperature ° C

 

 

 

 

 

Oxygen

saturation  (%)

 

 

 

 

Respiratory rate

breaths/minute

 

 

 

 

Heart rate

beats/minute

 

 

 

 

Systolic BP mmHg

 

 

 

 

 

Diastolic BP mmHg

 

 

 

 

 

Raised JVP (cm)

 

 

 

 

 

Capillary refill time (seconds)

 

 

 

 

Abdomen tender?

Yes    No 

Yes    No 

Yes    No 

Yes    No 

Pale/Anaemia

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

Hydration                       

Oral fluids in past 24 h (mL)

 

 

 

 

Dehydration

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

Urine output

(circle)

Normal       None Reduced     Unk

Normal     None Reduced     Unk

Normal     None Reduced     Unk

Normal     None Reduced     Unk

Vomiting    

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

None  Mild

Mod   Sev       

Stool freq

(#/24 hr)

 

 

 

 

Main stool type

F ormed

S emi-formed

L iquid N one

F ormed

S emi-formed

L iquid N one

F ormed

S emi-formed

L iquid N one

F ormed

S emi-formed

L iquid N one

 

 

Time (24 hr)

Date: DD/MM

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__ __ / __ __

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__ __ / __ __

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Overall symptoms

S ame B etter

W orse

S ame B etter

W orse

S ame B etter

W orse

S ame B etter

W orse

Fatigue

N one    M ild

M od     S ev       

N one    M ild

M od     S ev       

N one    M ild

M od     S ev       

N one    M ild

M od     S ev       

Headache

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Joint/muscle pains

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Unable to drink

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Unable to eat

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Difficult to swallow

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Hiccups

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Cough

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Difficult to breathe

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Rash

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Abdominal pain

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Urine pain

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Bleeding?

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

If yes for bleeding , which sites?

 

  Nose/oral

  Cough

  Vomit

  Stool

  Vaginal (not

       menstrual)

  Other (list)

  Nose/oral

  Cough

  Vomit

  Stool

  Vaginal (not

       menstrual)

  Other (list)

  Nose/oral

  Cough

  Vomit

  Stool

  Vaginal (not

       menstrual)

  Other (list)

  Nose/oral

  Cough

  Vomit

  Stool

  Vaginal (not

       menstrual)

  Other (list)       

Other symptoms (list)

 

 

 

 

 

 

 

 

 

 

 

 

 

* ASSUME PATIENT ON STANDARD ORAL TREATMENT PACKAGE UNLESS STATED OTHERWISE

Time (24 hr)

Date: DD/MM

__ __ : __ __

__ __ / __ __

__ __ : __ __

__ __ / __ __

__ __ : __ __

__ __ / __ __

__ __ : __ __

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Fluid management

1=ORS; 

2=Jelly Water

3=IV Maintenance

4= IV /IO Resuscitate

5= Blood transfusion

6= Fluid Restrict

 

   1       2

 

      3       4

 

       5       6

 

   1       2

 

      3       4

 

       5       6

 

   1       2

 

      3       4

 

       5       6

 

   1       2

 

      3       4

 

       5       6

Target volume in next 24 h (mL)

 

 

 

 

 

Antimalarials

AL (ACT)       

Artesunate       

Quinine     

AL (ACT)       

Artesunate       

Quinine     

AL (ACT)       

Artesunate       

Quinine     

AL (ACT)       

Artesunate       

Quinine     

Antibiotics

Ceftriaxone       

Cefixime       

Metronidazole

Ceftriaxone       

Cefixime       

Metronidazole

Ceftriaxone       

Cefixime       

Metronidazole

Ceftriaxone       

Cefixime       

Metronidazole

Analgesics / Antipyretics

Paracetamol       

Tramadol       

Morphine     

Paracetamol       

Tramadol       

Morphine     

Paracetamol       

Tramadol       

Morphine     

Paracetamol       

Tramadol       

Morphine     

Other (specify)

 

 

 

 

 

Date (DD/MM)

___/___

Clinical impression:

Problem list:

 

Date (DD/MM)

___/___

Clinical impression:

Problem list:

 

Date (DD/MM)

___/___

Clinical impression:

Problem list:

 

Date (DD/MM)

___/___

Clinical impression:

Problem list: