| Code | Display | Definition |
| paediatric-admission-record |
Paediatric admission record |
The three-page structured admission record used on the paediatric ward: presenting illness, immunisation, examination by system, investigations ordered and the coded admission diagnoses. |
| newborn-admission-record |
Newborn admission record |
The structured admission record for a baby admitted to the newborn unit, including intranatal history and the newborn examination. |
| newborn-observation-chart |
Newborn observation chart |
Apgar at one, five and ten minutes, the observations taken during the first two hours of skin-to-skin, and the twice-daily newborn follow-up over the first four days. |
| maternity-record |
Maternity record |
The maternity admission record: present pregnancy, past obstetric history, examination on admission, the plan, and the report on labour or caesarean section. |
| bishop-score |
Bishop score |
Cervical assessment before induction of labour, scored across dilation, effacement, consistency, position and station. |
| paediatric-triage-record |
Paediatric triage record |
The casualty triage sheet for a child: triage level, vital signs, the SAMPLE history and the emergency and priority signs looked for. |
| surgical-safety-checklist |
Surgical safety checklist |
The hospital's pre-operative and post-operative ward checklist together with the WHO three-phase theatre checklist. |
| anaesthetic-record |
Anaesthetic record |
The intra-operative anaesthetic chart: technique, agents, the observations recorded through the case, blood loss and the reversal and post-operative instructions. |
| palliative-care-assessment |
Palliative care assessment |
The palliative care service's first assessment: the symptom checklist, prior oncological treatment, and the social and spiritual assessment with the problem and action plan. |
| blood-donor-questionnaire |
Blood donor questionnaire |
The Kenya Tissue and Transplant Authority donor form (FRM CLN 001): donor details, the deferral questionnaire, the declaration and consent, and the donor screening and donation outcome. |
| haemodialysis-session-record |
Haemodialysis session record |
The dialysis flow chart for one session: access and virology screen, the prescription, the machine check and the observations taken through the run. |
| imaging-request |
Imaging request |
The X-ray and ultrasound request forms, which ask the same four things: what is wanted, why, the clinical summary and how urgently. |
| chemotherapy-prescription |
Chemotherapy prescription |
The oncology prescription sheet: staging and body surface area, the mandatory pre-cycle investigations, pre- and post-hydration, premedication and the cytotoxic drugs by cycle. |
| discharge-summary |
Discharge summary |
The sheet the patient leaves with: diagnoses, clinical summary, management given, discharge medication and instructions, plus the ward clearance sign-off. |
| procedure-consent |
Consent for a procedure or treatment |
The hospital's general consent form for an operation or treatment, and the two procedure-specific variants for endoscopy and for systemic anti-cancer therapy. |
| icu-neurological-chart |
ICU neurological observation chart |
The 24-hour ICU chart: Glasgow Coma Scale, limb power, pupils and vitals, charted round by round rather than once a shift, because a deteriorating conscious level is only visible as a series. |
| decline-form |
Decline form |
The bilingual form on which a patient or their next of kin records a refusal of care, a procedure or an assessment, and where they are going instead. |
| endoscopy-investigation |
Endoscopy service investigation form |
The endoscopy unit's single sheet: the request, the procedure, the findings, the conclusion and the treatment suggested. |
| medical-report |
Medical report |
A report on a completed admission written for someone outside the treating team -- an insurer, a court, another hospital. |
| patient-referral |
Patient referral form |
The form on which a patient is referred on to another unit or facility, carrying the history, the working diagnosis, the treatment already given and the reason for referral. |
| psychological-review |
Psychological review notes |
A counselling or therapy session recorded as a SOAP note, numbered within the episode of care. |
| blood-requisition |
Blood requisition form |
The blood bank requisition: products requested, recipient group, each issued unit with its bag number and cross-match result, and any transfusion reaction. |
| paediatric-nutrition-assessment |
Paediatric nutrition assessment form |
The nutrition unit's assessment of a child: family and feeding history, anthropometry, nutritional diagnosis and prescription. |
| prescription-pad |
Prescription |
The out-patient prescription slip: five numbered lines and a doctor's signature, with no dose or frequency column of its own. |
| mortality-committee-findings |
Mortality committee findings and recommendations |
The death review: nine numbered questions from the presenting complaint through to the committee's opinion and its recommendation. |
| chemotherapy-protocol-cycles |
Chemotherapy protocol cycle record |
The 2-, 3- and 4-weekly protocol sheet: one row per cycle carrying the counts and renal function that decide whether the cycle runs. |
| family-conference |
Patient, family and doctors' conference record |
The record of a conference held with a patient and their family, including any resuscitation decision reached. |
| icu-observation-chart |
ICU observation chart |
The 24-hour intensive care chart: vitals and CVP, the arterial blood gas, and the ventilator settings, round by round. |
| hdu-input-output-chart |
HDU input and output chart |
The high dependency unit's hourly fluid balance: parenteral and oral intake against aspirate, vomit, drain, urine and stool, with the 24-hour balance. |
| lab-requisition-serology |
Medical laboratory requisition |
The general laboratory requisition: specimen, urgency, clinical history and the investigations wanted, with the result and dispatch block on the same sheet. |
| newborn-unit-handover |
Newborn unit handover form |
The handover taken when a baby arrives in the newborn unit: intranatal history, ANC profile, birth history and the first vital signs. |
| newborn-comprehensive-chart |
Newborn comprehensive chart |
The newborn unit's daily sheet: the feed and fluid prescription, the IV nursing plan, the interventions in place, hourly observations, and a shift note with the baby's acuity category. |
| plates-and-screws |
Plates and screws |
The orthopaedic implant tally: forty printed line items with a count against each, signed at the foot. |
| head-injury-chart |
Head injury and craniotomy chart |
The one- or two-hourly neurological chart used after a head injury or a craniotomy: its own four-point conscious level, pupils per side, fits, spontaneous movement and paralysis by limb. |
| theatre-miscellaneous-items |
Theatre miscellaneous items |
The tally of consumables issued from theatre stock against one patient. |
| outpatient-summary |
Out-patient summary form |
The out-patient visit summary: complaints, provisional diagnosis and interventions. |
| patient-satisfaction |
Patient satisfaction questionnaire |
The service-quality survey given to out-patient, casualty, MCH and in-patient users. The only form in this set with no clinical extraction. |
| coagulation-profile-requisition |
Coagulation profile requisition |
The coagulation requisition, which prints its own reference ranges for PT, INR and APTT -- the INR range applying only to a patient on stabilised oral anticoagulants. |
| mortuary-services-request |
Mortuary services request form |
The request that accompanies a body into the mortuary, covering both hospital deaths and bodies brought from home or by the police. |
| mortuary-release |
Mortuary release form |
The release of a body for transfer to another hospital's morgue. |
| mortuary-baby-disposal-consent |
Mortuary consent form, disposal of a baby |
The authorisation given by a parent or next of kin for the hospital to dispose of a baby's body. |
| mortuary-admission |
Mortuary admission form |
The admission of a body into the mortuary: registration tag, where the body came from, next of kin and the relatives accompanying it. |
| body-part-disposal-consent |
Body part disposal consent form |
The consent taken before surgery for what happens to a removed body part -- released to the family, or disposed of by the hospital. |
| paediatric-nebulization-chart |
Paediatric nebulization chart |
Each nebulisation given: the drug, the amount and the frequency, with the time it was given and who gave it. |
| surgical-irrigation-record |
Surgical continuous irrigation record |
The hourly balance of a continuous bladder irrigation: solution and volume in against volume out, with the colour of the return. |
| milk-feeding-chart |
Milk feeding chart |
The three-hourly feed target against what was actually given, what was retained, and whether the baby passed urine and stool. |
| vent-monitoring-chart |
Ventilator monitoring chart |
The ventilator settings charted over time: mode, PEEP, peak inspiratory pressure and FiO2, with the changes made. |
| cpap-monitoring-chart |
CPAP monitoring chart |
The CPAP settings charted over time: the distending pressure, the gas flow and FiO2, with the change made at each reading and any remark. The ventilator chart's shape with two fewer columns. |
| embalming-authorization |
Embalming authorization form |
The next of kin's authorisation for a body to be embalmed while the burial is arranged. |
| paediatric-vital-sign-chart |
Paediatric vital sign observation chart |
Four observation rounds a day over ten days: temperature and how it was controlled, pulse, respiration, blood pressure, oxygen saturation and any oxygen given. |
| admission-form |
Admission form |
The nursing admission: where the patient came from and how they arrived, the presenting symptoms, a head-to-toe assessment, the chronic illness history, and the investigations and treatment ordered on arrival. |
| rehabilitation-services |
Rehabilitation services record |
Each rehabilitation contact: the units billed, the devices and materials used, and the progress note. |
| nicu-monitoring-chart |
NICU monitoring chart |
The neonatal unit's hourly chart: vitals, an assessment including jaundice and apnoea, the ventilator settings and the blood gas. |
| theatre-pacu-observation |
Theatre PACU observation form |
Timed recovery-room observations after anaesthesia, with the drugs given and remarks. |
| pacu-nurses-notes |
PACU nurses notes |
The recovery-room nursing narrative, timestamped and signed per entry. |
| theatre-note |
Theatre note |
The operation note: diagnosis, procedure, incision, the surgical and anaesthetic team, and the description of what was done. |
| doctors-notes |
Doctors notes continuation sheet |
The ward round narrative, timestamped and signed per entry. |
| surgical-dressing-chart |
Surgical dressing chart |
Each dressing change, with the sheet's own three-letter grading and a remark. |
| feeding-and-position-chart |
Feeding and position chart |
How much a patient was fed and how they were positioned, entry by entry -- turning is what prevents pressure injury and this is where it is evidenced. |
| nursing-care-plan |
Nursing care plan |
The full nursing process per problem: assessment, nursing diagnosis, expected outcome, intervention, the scientific rationale for it, what was implemented and the evaluation. |
| intake-output-record |
Intake and output record |
The 24-hour fluid balance: oral, IV and nasogastric intake against urine, stool, vomit, nasogastric suction and drainage, with the totals the sheet asks to be circled. |
| antenatal-vital-signs |
Antenatal vital signs |
Timed antenatal observations: temperature, pulse, respiration and blood pressure with the lie, the presentation, the fetal heart tones and whether the bowels have opened. |
| paediatric-tb-icf-screening |
Paediatric TB intensified case finding screening tool |
The five-question intensified case finding screen asked of every child at every contact -- cough of any duration, fever, failure to thrive or poor weight gain, lethargy, and contact with a TB case -- and the action the answers decide. Table 22.9 of the paediatric TB guideline. |