Immunisation history: Complete/ Incomplete (If incomplete give details) Condition on Admission Breathing breathing in drawing □Normal □Severe chest breathing or gasping □Central cyanosis □Not Consciousness Stable Convulsions Unconscious □ □ □ level Semi-conscious, responds to verbal commands □ Semi-conscious, responds to painful stimuli □ Circulation to touch / colder than the abdomen □Eextremities:warm □Weak and fast pulse: whether 1+/2+/3+ □Capillary Refill Time: □<3 seconds □>3seconds Other symptoms □Dehydration □Bleeding □Icterus rashes or □Petechial bruising □Trauma/ urgent surgical condition of both feet Severe wasting □Burns □Oedema □ Severe cyanosis □Ear Discharge □ Total Duration hours -7 days days days □<48 hours □48 □8-14 □14-21 of stay in the than 21 days □More health facility Investigations □Blood glucose □CBC □Urine test Renal function tests □ CSF □ Widal test □ Serum bilirubin □ culture □Blood □Liver Function Test □Urine culture Others (specify) □ REFERRAL DETAILS Was the child referred from Yes/ No /Don’t know another Centre? If yes, Type of facility from 24x7PHC SDH/Rural Hospital/CHC which referred? District Hospital Private Hospital Private clinic medical college/Specialty Hospitals Others TREATMENT DETAILS Oxygen use Yes No IV Fluids Yes No Antibiotics Yes No Anti malarials Yes No Anticonvulsants Yes No Bronchodilators Yes No Blood Components Yes No Steroids Yes No Yes No Anti tubercular drugs Yes No Antiretroviral drugs Vasopressors (Dopamine/Dobutamine/Adrenaline) Yes No Respiratory support (CPAP/Ventilator) Yes No Surgical interventions Yes No Other interventions (provide details)
Immunisation history: Complete/ Incomplete (If incomplete give details) Condition on Admission Breathing □Normal breathing □Severe chest in drawing □Central cyanosis □Not breathing or gasping Consciousness level □ Stable □ Convulsions □ Unconscious □ Semi-conscious, responds to verbal commands □ Semi-conscious, responds to painful stimuli Circulation □Eextremities:warm to touch / colder than the abdomen □Weak and fast pulse: whether 1+/2+/3+ □Capillary Refill Time: □<3 seconds □>3seconds Other symptoms □Dehydration □Bleeding □Icterus □Petechial rashes or bruising □Trauma/ urgent surgical condition □Burns □Oedema of both feet □ Severe wasting □Ear Discharge □ Severe cyanosis Total Duration of stay in the health facility □<48 hours □48 hours -7 days □8-14 days □14-21 days □More than 21 days Investigations □Blood glucose □CBC □Urine test □ Renal function tests □ CSF □ Widal test □ Serum bilirubin □Blood culture □Liver Function Test □Urine culture □ Others (specify) REFERRAL DETAILS Was the child referred from another Centre? Yes/ No /Don’t know If yes, Type of facility from which referred? 24x7PHC SDH/Rural Hospital/CHC District Hospital Private Hospital Private clinic medical college/Specialty Hospitals Others TREATMENT DETAILS Oxygen use Yes No IV Fluids Yes No Antibiotics Yes No Anti malarials Yes No Anticonvulsants Yes No Bronchodilators Yes No Blood Components Yes No Steroids Yes No Anti tubercular drugs Yes No Antiretroviral drugs Yes No Vasopressors (Dopamine/Dobutamine/Adrenaline) Yes No Respiratory support (CPAP/Ventilator) Yes No Surgical interventions Yes No Other interventions (provide details)
Facility%20Based%20%20Child%20Death%20Review%20Form(_revised).docx