Internal Medicine and Surgery

REPUBLIC OF RWANDA REPUBLIC
RUHANGO OF RWANDA
HOSPITAL
SOUTHERN PROVINCE
MINISTRY OFHEALITH
MINISTRY OF HEALTH NYARUGURU DISTRICT
P.O Box 84 Kigali MUNINI HOSPITAL
www.moh.gov.rw
INIPATIENT FILE/
DOSSIER HOSPITALISATION
MATERNITE
Department of INTERNAL MEDICINE AND SURGERY
PATIENT NAMES Initials ......................................

PATIENT NUMBER/ NUMERO DU DOSSIER:
6 (NUMBER)- 4 (YEARS)
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MUNINI HOSPITAL
IDENTIFICATION INFORMATION
LAST NAME/NOM: FIRST NAME/ PRENOM:
DATE OF BIRTH/ DATE DE NAISSANCE (dd/mm/yyyy):

SEX/SEXE: MALE FEMALE
............... /............... /.................
MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED
FATHER/PERE: MOTHER /MERE:
NATIONALITY:
NATIONAL ID/ CARTE D’IDENTITE: PASSPORT No:
HOME ADDRESS
COUNTRY/IGIHUGU
PROVINCE/INTARA
DISTRICT/AKARERE
SECTOR/UMURENGE
CELL/AKAGALI
VILLAGE/UMUDUGUDU
OCCUPATION/PROFESSION: RELIGION: TELEPHONE:
CONTACT PERSON IN CASE OF EMERGENCY
NAMES: TELEPHONE:
HEALTH INSURANCE YES NO INSURANCE NUMBER:
Mutuelle RSSB MMI MEDIPLAN CORAR NUR OTHER (list):.......
HEALTH STATUS
KNOWN ALLERGIES: BLOOD GROUP:
KNOWN CHRONIC
DISEASES/
CONDITIONS
Note: Complete the area of allergies with a red color
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MUNINI HOSPITAL
FIRST ADMISSION Ward:
DATE OF ADMISSION (dd/mm/yyyy) : / / MODE OF ADMISSION: Voluntary Transfer from: ....................
RECOVERED IMPROVED UNIMPROVED
DIED BEFORE 48 HR: DIED AFTER 48 HR: AUTOPSY REQUESTED:
FLED: REFERRED TO:
DISCHARGE DATE (dd/mm/yyyy) : / /
CLINICAL SUMMARY: ICD-10

………………………………………………………………………………………………………………………………………………………………………………………………………………… or
…………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………… ICPC
code
FINAL DIAGNOSIS:
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INVESTIGATION SUMMARY:
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OTHER DIAGNOSIS:
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SECOND ADMISSION Ward:
DATE OF ADMISSION (dd/mm/yyyy) : / / MODE OF ADMISSION: Voluntary Transfer from:.............
RECOVERED IMPROVED UN IMPROVED
DIED BEFORE 48 HR: DIED AFTER 48 HR: AUTOPSY REQUESTED:
FLED: REFERRED TO:
DISCHARGE DATE (dd/mm/yyyy) : / /
ICD-10
CLINICAL SUMMARY: or
…………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………................................................................................... ICPC
code
FINAL DIAGNOSIS:
…………………………………………………………………………………………………………………………………………………………………………………………………………………
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INVESTIGATION SUMMARY:...........................................................................................................................................................................
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OTHER DIAGNOSIS:.........................................................................................................................................................................................
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REPUBULIKA Y’U RWANDA
INTARA Y’AMAJYEPFO
AKARERE KA NYARUGURU
IBITARO BYA MUNINI
KWEMERERA/KWANGA KUVURWA
Njyewe, ……………………………………………,nyuma yo gusobanurirwa uburwayi

bwanjye;……………………………………….., mpaye uburenganzira abaganga nabo bafatanya
mu bijyanye no kumvura:………………………………………………………………..
Nzineza ko abaganga nabo bafatanya bafite ibyo bazankorera bimfitiye akamaro.Bansobanuriye

Akamaro,Inyungu n’ingaruka kubijyana n’uburyo bwose bwo kuvurwa ,ingaruka zishobora kuba
ndamutse nanze kuvurwa bazinsobanuriye.Ndemeza ko nasobanuriwe uburyo bwose bushoboka
bwo kumvura.Ikindi ni uko nubwo bansobanuriye ingaruka n’inyungu zishoboka, hashobora
kubaho ingorane zitateganijwe.Abaganga n’abo bafatanya kuvura bakaba bakora ibishoboka
byose bimfitiye inyungu hagendewe k’ubuhanga n’ubunararibonye bafite mu mwuga
w’ubuvuzi.Nahawe umwanya wo kubaza ibibazo kandi nanyuzwe n’ibisubizo nahawe, nkaba
ntahejwe no kongera kubaza
Ndemera□ / Sinemera□abaganga ndetse n’abobafanyakumvura
Nemereye□ / Sinemereye□ Muganga ndetse nabo bafatanije, kumvura ubundi burwayi

bwaboneka nyuma.
……/……/.... …………… …………………………………………….

Itariki/Isaha/Umukono w’Umurwayi
……/……/.... …………… …………………………………………….
Itariki/Isaha/Umukono w’Umwishingizi
Icyo apfana n’umurwayi…………………………………………………………
……/……/.... …………… …………………………………………….

Itariki/Isaha/Umukono w’Umuforomo/Umubyaza
INDAHIRO YA MUGANGA:
Dr/Mr/Mrs/Miss………………………………………..Ndemeza ko amakuru yose ajyanye
n’uburwayi, uburyo bwo kuvurwa n’ingaruka zishobora kubaho, byasobanuriwe
Umurwayi/Umwishingizi mu buryo bwihariye bigendeye k’uburwayi bwe/ bw’uwo ahagarariye.
Umukono wa Muganga ……………………………… Itariki………/……../…………..Isaha
Amazina ya muganga:………………………………………………………….
Umukono w’umuforomo……………………………… Itariki………/……../…………..Isaha
Amazina y’umuforomo :……………………………………..
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IBITARO BYA MUNINI
KWEMERA/KWANGA GUTERWA IKINYA
Njyewe………………………………………………………………………………………………………
nyuma yo gusobanurirwa;guhabwa umwanya wo kubaza ibibazo narimfite kubijyanye no
guterwa ikinya no kubwirwa ubwoko bw’ikinya ngomba guterwa/umurwayi wanjyeagomba
guterwa bitewe n’uburwayi bwanjye/afite,n’ingaruka ikinya gishobora gutera izo arizo zose.
Ndemera□ / Sinemera□ko nterwa ikinya/umurwayi aterwa ikinya na

Dr/Mr/Mrs/Ms ………………………………………………………………………..hamwe n’abo
bafatanije.
Ndemera□ / Sinemera□kandi ko mu gihe cyo kubagwa;ubwoko bw’ikinya bampitiramo

bwose/ bahitiramo umurwayi wanjye bujyanye n’uburwayi bwanjye/ uburwayi bwe babutera.
……/……/.... …………… …………………………………………….

Itariki/Isaha/Umukono/\ w’Umurwayi
……/……/.... …………… …………………………………………….
……/……/.... …………… …………………………………………….

INDAHIRO Y’UTERA IKINYA:

Dr/Mr/Mrs/Ms…………………………………………………………; Ndemeza ko nasobanuriye
namuhaye umwanya wo kubaza ibibazo yari afite kubijyanye no guterwa ikinya; namubwiye
ubwoko bw’ikinya ngomba kumutera/gutera umurwayi yishingiye bitewe n’uburwayi bwe/uwo
yishingiye,n’ingaruka ikinya gishobora kumutera.
.
……/……/.... …………… …………………………………………….
Itariki/Isaha/Umukono w’utera ikinya
4
IBITARO BYA MUNINI
KWEMERA/KWANGA GUTERWA AMARASO

Njyewe, ………………………………………………,maze gusobanurirwa ko nkeneye/uwo
nishingiye akeneye,cyangwa nshobora/ashobora gukenera guterwa amaraso cyangwa se bimwe
mu biyagize bitewe n’impamvu ikurikira:
……………………………………………………………………………………………..
Nasobanuriwe muri rusange icyo guterwa amaraso aricyo,uko bikorwa n’ibyiza byabyo nko:
guhagarika kuva,gufasha umutima gukomeza gukora,kongera insoro z’amaraso no gukiza
ubuzima bwanjye/bw’umurwayi wanjye.Nasobanuriwe ko mu gihe nanze guterwa/
uwonishingiye aterwa amaraso bishobora guteza ingarukambi k’ubuzima bwanjye /uwo
nishingiye harimo n’urupfu.Nasobanuriwe ingaruka zishobora kuva ku guterwa amaraso,
zirimo:kugira umuriro, gusesa,uduheri,kwishima ndetse n’urupfu.Nasobanuriwe ko ibi byose
bishobora kubaho nubwo amaraso aba yapimwe neza mbere yo kuyantera.
Nyuma y’ibyo bisobanuro;
Ndemera□ / guterwa/uwo nishingiye aterwa amaraso.
Sinemera□guterwa/uwo nishingiye aterwa amaraso nubwo nasobanuriwe nkanumva ko

bishobora kumviramo kugira ubumuga bwa burundu cyangwa urupfu
……/……/.... …………… …………………………………………….
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……/……/.... …………… …………………………………………….

Itariki/Isaha/Umukono w’Umuforomo/ Umubyaza
Dr/Mr/Mrs/Miss……………………………Ndemeza ko nahaye umurwayi/ umwishingizi

amakuru yose ajyanye n’uburwayi bwe/uwoyishingiye,uburyo bwo gutera amaraso, ingaruka
zishobora kubaho mugihe umurwayi/umwishingizi yanze guterwa/gutera uwo yishingiye amaraso
n’ingaruka zishobora kubaho mu gihe atewe amaraso.
……/……/.... …………… …………………………………………….
Itariki/Isaha/Umukono wa Muganga
5
IBITARO BYA MUNINI
KWEMERERA/KWANGA KUVURWA UBAZWE
Njyewe, ……………………………………………, nyuma yo gusobanurirwa uburwayi

bwanjye;………………………………………………….., mpaye uburenganzira
Dr………………………………………………….n’abandibafasha be mu bijyanye no kumvura;
kunkorera…………………………………………………………………..
Inyungu n’ingaruka kubijyana nubu buryo bwo kuvurwa babinsobanuriye.Zimwe mu ngaruka

zishobora kuba n’izi zikurikira ariko urutonde ntirurangiye: kuva cyane mugihe cyo kubagwa,
gutinda gukira kw’igisebe nyuma yo kubagwa,ibibazo by’umutima, gutakaza ingingo
burundu cyangwa gukora kwazo,bishobora no gutera urupfu. Ndemeza ko nasobanuriwe
Ubundi buryo bushoboka bwo kumvura.
Ndemera□ / Sinemera□guterwa amaraso mugihe byaba ngombwa akaba arinabwo buryo

bwonyine bwo kuvurwa mugihe habayeho kuva gukabije mu gihe cyo kubagwa.
Nemereye□ / Sinemereye□Muganga gufata amashusho,amafoto, ndetse nabimwe mubice

by’umubiri wanjye byabonetse mu kubagwa, bikazakoreshwa gusa mubijyanye n’ubushakashatsi
kandi ibindanga ntibigaragazwe.
Nemereye□ / Sinemereye□Muganga ndetse nabo bafatanije,ko mu gihe habonetse uburwayi

butari bwamenyekanye mbere yuko mbagwa ngo mbusobanurirwe, gukora ibishoboka byose
bimfitiye inyungu hagendewe k’ubuhanga n’ubunararibonye bafite mu mwuga w’ubuvuzi.
……/……/.... …………… …………………………………………….

……/……/.... …………… …………………………………………….
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Dr/Mr/Mrs/Miss………………………………………..Ndemeza ko amakuru yose ajyanye
n’uburwayi, uburyo bwo kuvurwa n’ingaruka zishobora kubaho, byasobanuriweUmurwayi/
Umwishingizi mu buryo bwihariye bigendeye k’uburwayi bwe/ bw’uwo ahagarariye.
.
……/……/.... …………… …………………………………………….
Itariki/Isaha/Umukono wa Muganga
6
ADULT TRIAGE FORM (Over 12 Years) Chief Complaint: ............................................................................Date: ............
Names: .........................................................................................Age: ........... Arrival time: .........h.......Medical Record Number:..... .
EMERGENCY SINGS? CHECK THE COMPLAINT

Airway/ Breathing Not breathing Obstructed breathing Severe respiratory distress Circle Triage Color
Circulation Cardiac arrest Hemorrhage-uncontrolled Stab/gunshot wound to neck or chest
Lethargic Pulse weak and fast Cap refill ≥3 sec Cold hand plus RED
Convulsion: Current seizure or post ictal (not alert) (Glucose= ..............................) Yes Immediate
Resuscitation
Coma: Un responsive or responsive only to pain (Glucose+ ...................)
ALARM
Dehydration: Severe dehydration ≥ +2 of following Skin pinch ≥ 2sec Lethargy Sunken eyes
Other : Hypoglycemia (Glucose < 3 mmol/L/60mg/dl Purpuric rash Burn-face/inhalation
No
Calculate triage EARLY WARNING SCORE (TEWS) -CIRCLE THE BOX

SCORE 3 2 1 0 1 2 3
Mobility Walking With help Stretcher
Wheelchair Immobile
RR <9 9-14 15-20 21-29 >29
HR <41 41-50 51-100 101-110 11-129 >129
SBP <71 71-80 81-100 101-199 >199
Temp <35 35-38.4 >38.5
AVUP Confused Alert React to Voice React to pain Unresponsive
Trauma No Yes
Total score
O2 Saturation RED
Pain (0-10) Immediate Resuscitation
TEWS =7-14 or O2 Saturation <92%
ORANGE
TEWS=0-4 TEWS =5-6
Less than 10 min
Very Urgent Sings? CHECK THE COMPLAINT
Medical Trauma Yes
Focal neurological deficit-acute (<1day) (Glucose) Burn over 20%, or urgent signs
Altered mental status-acute (<1 day) (Glucose) (electrical, chemical or circumferential)
Chest pain Fracture open (with skin break) No and TEWS=3-4
Poisoning/Overdose Threatened limb (no pulse or pale)
Coughing or vomiting blood Eye injury YELLOW
Unwell with diabetes, glucose>200mg/dl or 11mmol/l Dislocation of lager joint (not finger/toe) Within 60 min
Aggression Severe mechanism of injury (Fall>1
Shortenes of breath – acute (Less than 1 day) meter, RTA, other significant trauma)
Very severe pain (≥7) Abdominal trauma
No and TEWS=0-2 Yes
URGENT SIGNS? CHECK COMPLAINT

Medical Trauma
Unable to drink or vomits everything Very pale Dislocation -finger or toe No
Unable to drink or vomits everything Respiratory distress Fracture-closed
GREEN
Diabetic, not unwell but glucose>300mg/dl or 17mmol/l Burn without urgent signs
Within 4 hours
Severe malnutrition/wasting Moderate pain (5-6)
Nurse’s Names: ..........................................................Triage finish time: ....h........ Notified colour: RED/ORANGE@.....h.....min
Doctor’s Names: ................................................................................... Attended at: .......h........ For RED ORANGE
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MUNINI HOSPITAL
NURSING ASSESSMENT ON ADMISSION
Greet and introduce yourself, Yes No
Date:….…/…........../20…...... Time:.............h.........min
Names of the patient:…………………………………………………………..File No:………..
Reason of consultation/transfer:...………………………………………………………...........................
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Complaints:…………………………………………………………………………………………………………….
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Past Medical History:…………………………………………………………………………………………….
General status:…………………………………………………………………………………………………
Vital signs and other parameters: T………..°C, Pulse(Beat/min)…………..........................
B.P (mm/hg)…………….........RR (breath/min)………..................WEIGHT(kg)………….........
Danger signs:………………………………………………………………………………........................................
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First emergency care:………………………………………………………........................................................
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Call for the physician: Date……/……../20…… Time........h….…min
Name and signature of the nurse:………………………………………………...........
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MUNINI HOSPITAL
CLINICAL EXAMINATION
DATE OF ADMISSION (dd/mmm/yyyy):............/.........../.......... TIME OF ADMISSION: ………………………….
GENERAL EXAMINATION
GENERAL STATUS:.........................................................................................................................................
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PULSE
WEIGHT (Kg): HEIGHT (cm): BMI/IMC: B.P (mm/hg):
(Beat/min):
Mid Upper Arm Circumference
RESP.RATE (breath/min): TEMP.(°C): O2SAT.:
(MUAC)…….
CLINICAL HISTORY
CHIEF COMPLAINTS: ………………………………………………………………………………………………………………………………
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HISTORY OF PRESENT ILLNESS: ……………………………………………………………………………………………………………..

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PAST MEDICAL HISTORY: ……………………………………………………………………………………………………………………......
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PHYSICAL EXAMINATION/SYSTEMIC REVIEW
CENTRAL NERVEOUS SYSTEM (Glasgow, Reflexes, Muscle Power And Tonicity, Sensitivity and Motricity):
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HEAD:..............................................................................................................................................................
NECK:..............................................................................................................................................................
ENT:.................................................................................................................................................................
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CARDIOVASCULAR SYSTEM:.........................................................................................................................
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MUNINI HOSPITAL
CLINICAL EXAMINATION
RESPIRATORY SYSTEM: …………………………………………………………………………………………………………………………….
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GASTRO-INTESTINAL TRACT: ……………………………………………………………………………………………………………………
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GENITOURINARY SYSTEM: ………………………………………………………………………………………………………………………
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MUSCULOSKELETAL: ………………………………………………………………………………………………………………………………..
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CLINICAL SUMMARY: ……………………………………………………………………………………………………………………………....
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DIFFERENTIAL DIAGNOSIS: ……………………………………………………………………………………………………………………….
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MUNINI HOSPITAL
INVESTIGATIONS: ……………………………………………………………………………………………………………………………………..
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TREATMENT PLAN: ………............................................................................................................................................

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DOCTOR’S NAME, SIGNATURE AND STAMP
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MUNINI HOSPITAL
DIAGNOSIS AND DISCHARGE PLAN

DATE & TIME INVESTIGATIONS RESULTS DOCTOR’S NAMES,
SIGNATURE & STAMP
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.......................... CLINICAL/WORKING DIAGNOSIS:......................................................................................................
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TREATMENT:...............................................................................................................................................
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DISCHARGE PLAN: .............................................................................................................................
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MUNINI HOSPITAL
PROGRESS NOTE/ EVOLUTION
DATE & TIME PROGRESS NOTE, INVESTIGATIONS/TREATMENT
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Instruction: IT IS AN OBLIGATION TO PUT THE NAME, SIGNATURE & STAMP OF HEALTH PROFESSIONAL AFTER EVERY PATIENT REVIEW
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MUNINI HOSPITAL
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MUNINI HOSPITAL
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15
MUNINI HOSPITAL
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16
MUNINI HOSPITAL
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17
MUNINI HOSPITAL
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MUNINI HOSPITAL
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29
NURSING CARE PLAN
DATE & NURSING ASSESSMENT NURSING DIAGNOSIS/ OBJECTIVES INTERVENTIONS OUTCOMES NAME &
TIME PROBLEM SIGNATURE
20
Note: EVERY SHIFT MUST COMPLETE ITS NURSING CARE PLAN
NURSING CARE PLAN
21
NURSING CARE PLAN
22
NURSING CARE PLAN
23
24
25
26
27
28
29
30
HOSPITAL
MUNINI NAME
HOSPITAL
OBSERVATION/VITAL
HOSPITAL NAME
SIGNS SHEET
Date ......./......./......... ........./......./......... ......../......./................../......./................../......./................../......./.........
Blood Pressure
OBSERVATION/VITAL
M
SIGNS SHEET
M S M M S M M M S
M M S
FrequencyFrequency
Pulse M S M M S
Respiratory Rate
Blood Pressure
Temperature
Pulse
Respiratory Rate 42
Temperature 41
40
42
39
41
38
40
37
Temperature
39
36
38
35
37
Temperature
34
36
33
35
32
34
31
33
30
32
31
220
30
210
200
220
190
210
180
200
170
190
160
180
150
170
140
Blood Pressure/Pulse
160
130
150
120
140
110
130
100
120
90
110
80
100
70
90
60
80
50
70
40
60
30
50
20
40
30
60
20
50
40
Rate
60
30
50
Respiration
20
40
Rate
10
30
Respiration
200
10
O2 Saturation 0
WEIGHT
Fluid
O Input Total
Saturation
2
Fluid
WEIGHTOutput Total
Fluid Balance
Input Total
Nurse InitialsTotal
Fluid Output
Measurements in Gray areas should be repeated and if you get the same measurement take action and report to the Doctor Immediately
Fluid Balance
Nurse Initials
23
31
HOSPITAL
MUNINI NAME
HOSPITAL
OBSERVATION/VITAL
HOSPITAL NAME
SIGNS SHEET
Date ......./......./......... ........./......./......... ......../......./................../......./................../......./................../......./.........
Blood Pressure
OBSERVATION/VITAL
M
SIGNS SHEET
M S M M S M M M S
M M S
FrequencyFrequency
Pulse M S M M S
Respiratory Rate
Blood Pressure
Temperature
Pulse
Respiratory Rate 42
Temperature 41
40
42
39
41
38
40
37
Temperature
39
36
38
35
37
Temperature
34
36
33
35
32
34
31
33
30
32
31
220
30
210
200
220
190
210
180
200
170
190
160
180
150
170
140
160
130
150
120
140
110
130
100
120
90
110
80
100
70
90
60
80
50
70
40
60
30
50
20
40
30
60
20
50
40
Rate
60
30
50
Respiration
20
40
Rate
10
30
Respiration
200
10
O2 Saturation 0
WEIGHT
Fluid
O Input Total
Saturation
2
Fluid
WEIGHTOutput Total
Fluid Balance
Input Total
Nurse InitialsTotal
Fluid Output
Fluid Balance
Nurse Initials
36
23
32
MUNINI HOSPITAL
HOSPITAL NAME
OBSERVATION/VITAL
HOSPITAL NAME
SIGNS SHEET
Date ......./......./......... ........./......./......... ......../......./................../......./................../......./................../......./.........
Blood Pressure
OBSERVATION/VITAL
M
SIGNS SHEET
M S M M S M M M S
M M S
FrequencyFrequency
Pulse M S M M S
Respiratory Rate
Blood Pressure
Temperature
Pulse
Respiratory Rate 42
Temperature 41
40
42
39
41
38
40
37
Temperature
39
36
38
35
37
Temperature
34
36
33
35
32
34
31
33
30
32
31
220
30
210
200
220
190
210
180
200
170
190
160
180
150
170
140
160
130
150
120
140
110
130
100
120
90
110
80
100
70
90
60
80
50
70
40
60
30
50
20
40
30
60
20
50
40
Rate
60
30
50
Respiration
20
40
Rate
10
30
Respiration
200
10
O2 Saturation 0
WEIGHT
Fluid
O Input Total
Saturation
2
Fluid
WEIGHTOutput Total
Fluid Balance
Input Total
Nurse InitialsTotal
Fluid Output
Fluid Balance
Nurse Initials
23
23
33
MUNINI HOSPITAL
HOSPITAL NAME
OBSERVATION/VITAL
HOSPITAL NAME
SIGNS SHEET
Date ......./......./......... ........./......./......... ......../......./................../......./................../......./................../......./.........
Blood Pressure
OBSERVATION/VITAL
M
SIGNS SHEET
M S M M S M M M S
M M S
FrequencyFrequency
Pulse M S M M S
Respiratory Rate
Blood Pressure
Temperature
Pulse
Respiratory Rate 42
Temperature 41
40
42
39
41
38
40
37
Temperature
39
36
38
35
37
Temperature
34
36
33
35
32
34
31
33
30
32
31
220
30
210
200
220
190
210
180
200
170
190
160
180
150
170
140
160
130
150
120
140
110
130
100
120
90
110
80
100
70
90
60
80
50
70
40
60
30
50
20
40
30
60
20
50
40
Rate
60
30
50
Respiration
20
40
Rate
10
30
Respiration
200
10
O2 Saturation 0
WEIGHT
Fluid
O Input Total
Saturation
2
Fluid
WEIGHTOutput Total
Fluid Balance
Input Total
Nurse InitialsTotal
Fluid Output
Fluid Balance
Nurse Initials
38
23
34
NYAMATA HOSPITAL
33
35
NYAMATA HOSPITAL
34
36
FICHE DE SURVEILLANCE DE DIABETIQUE
Nom du patients:……………………………………………………………………………………………………………………………………..
Age:…………..
Date et Heure Glycémie Matinal Glycémie Soir Observation
37
PATIENT HEALTH EDUCATION RECORD
Department of:.................................................................................................Ward:...............................................................................................
Last Name:.............................................................................................................. First Name:.............................................................................
Patient File NO:...........................................................................................................................................................................................................
Next of Kin:..........................................................................................Relationship:................................................................................................
Diagnosis:..................................................................................................................................................................................................................
IDENTIFIED HEALTH EDUCATION NEEDS:.............................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
DATE & TIME SUBJECT INFORMATION RECEVED INFORMATION STAFF PATIENTS

BY THE PATIENT RECEVED NAME & SIGNATURE
BY THE NEXT KIN SIGNATURE
38
EMERGENCY TELEPHONIC PRESCRIPTION
Date Prescription Signature of Signature of Time Date Administered Medical Name and signature of
1st person 2nd person administere administere by whom pharmacist who
taking order taking order d d signature dispensed medication
39
MUNINI HOSPITAL
Note: Telephonic medication/sedation may be ordered by a who is not able to come to the Unit /Ward. Two Registered Nurses listen on a loud speaker to the order;
repeat it back separately to the write and sign up the order. The medication is administered to the patient and the order is signed by the
within 24hours or the next day in the Office.

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REPUBLIC OF RWANDA REPUBLIC

PATIENT NAMES Initials ......................................

LAST NAME/NOM: FIRST NAME/ PRENOM:

DATE OF BIRTH/ DATE DE NAISSANCE (dd/mm/yyyy):

MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED

FATHER/PERE: MOTHER /MERE:

NATIONAL ID/ CARTE D’IDENTITE: PASSPORT No:

OCCUPATION/PROFESSION: RELIGION: TELEPHONE:

CONTACT PERSON IN CASE OF EMERGENCY

HEALTH INSURANCE YES NO INSURANCE NUMBER:

Mutuelle RSSB MMI MEDIPLAN CORAR NUR OTHER (list):.......

KNOWN ALLERGIES: BLOOD GROUP:

Note: Complete the area of allergies with a red color

FIRST ADMISSION Ward:

DATE OF ADMISSION (dd/mm/yyyy) : / / MODE OF ADMISSION: Voluntary Transfer from: ....................

RECOVERED IMPROVED UNIMPROVED

DIED BEFORE 48 HR: DIED AFTER 48 HR: AUTOPSY REQUESTED:

FLED: REFERRED TO:

DISCHARGE DATE (dd/mm/yyyy) : / /

CLINICAL SUMMARY: ICD-10

SECOND ADMISSION Ward:

DATE OF ADMISSION (dd/mm/yyyy) : / / MODE OF ADMISSION: Voluntary Transfer from:.............

RECOVERED IMPROVED UN IMPROVED

DIED BEFORE 48 HR: DIED AFTER 48 HR: AUTOPSY REQUESTED:

FLED: REFERRED TO:

DISCHARGE DATE (dd/mm/yyyy) : / /

Njyewe, ……………………………………………,nyuma yo gusobanurirwa uburwayi

Nzineza ko abaganga nabo bafatanya bafite ibyo bazankorera bimfitiye akamaro.Bansobanuriye

Nemereye□ / Sinemereye□ Muganga ndetse nabo bafatanije, kumvura ubundi burwayi

……/……/.... …………… …………………………………………….

……/……/.... …………… …………………………………………….

Icyo apfana n’umurwayi…………………………………………………………

……/……/.... …………… …………………………………………….

Umukono w’umuforomo……………………………… Itariki………/……../…………..Isaha

Amazina y’umuforomo :……………………………………..

KWEMERA/KWANGA GUTERWA IKINYA

Ndemera□ / Sinemera□ko nterwa ikinya/umurwayi aterwa ikinya na

Ndemera□ / Sinemera□kandi ko mu gihe cyo kubagwa;ubwoko bw’ikinya bampitiramo

……/……/.... …………… …………………………………………….

……/……/.... …………… …………………………………………….

Icyo apfana n’umurwayi…………………………………………………………

……/……/.... …………… …………………………………………….

INDAHIRO Y’UTERA IKINYA:

KWEMERA/KWANGA GUTERWA AMARASO

Ndemera□ / guterwa/uwo nishingiye aterwa amaraso.

Sinemera□guterwa/uwo nishingiye aterwa amaraso nubwo nasobanuriwe nkanumva ko

……/……/.... …………… …………………………………………….

……/……/.... …………… …………………………………………….

Dr/Mr/Mrs/Miss……………………………Ndemeza ko nahaye umurwayi/ umwishingizi

……/……/.... …………… …………………………………………….

KWEMERERA/KWANGA KUVURWA UBAZWE

Njyewe, ……………………………………………, nyuma yo gusobanurirwa uburwayi

Inyungu n’ingaruka kubijyana nubu buryo bwo kuvurwa babinsobanuriye.Zimwe mu ngaruka

Ndemera□ / Sinemera□guterwa amaraso mugihe byaba ngombwa akaba arinabwo buryo

Nemereye□ / Sinemereye□Muganga gufata amashusho,amafoto, ndetse nabimwe mubice

Nemereye□ / Sinemereye□Muganga ndetse nabo bafatanije,ko mu gihe habonetse uburwayi

……/……/.... …………… …………………………………………….

……/……/.... …………… …………………………………………….

Icyo apfana n’umurwayi…………………………………………………………

……/……/.... …………… …………………………………………….

Names: .........................................................................................Age: ........... Arrival time: .........h.......Medical Record Number:..... .

EMERGENCY SINGS? CHECK THE COMPLAINT

Calculate triage EARLY WARNING SCORE (TEWS) -CIRCLE THE BOX

URGENT SIGNS? CHECK COMPLAINT