| 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. |