File Number:

Ingwavuma Hospice & Orphan Care

PO Box 272, Ingwavuma, 3968. NPO 010-354

Paediatric Medical Record

HBC Team:
Date of first assessment:

Assigned staff
Name of main HBC care giver: Name of nurse supervising caregiver :

Patient Details
Surname: Date of Birth or Age: Isigodi: First Name: ID number Gender: Male / Female

Family Details
Primary Caregiver: Relationship to patient: Age of caregiver: Legal guardian: Relationship to child: Gender of caregiver :

CARES Score: (write in new level only when the condition changes) Date Level
Level 1: All green Level 2: Any yellow, some green, no red

Level 3: Any red

Medical assessment- (to be done by nurse)

Immunisations up to date?: Current Diagnoses: Yes No

Past illnesses: Current medication:

Current symptoms: None (green)

Mild-moderate (yellow)

Severe (red)

Physical examination: (Skin sores, ears, mouth, lymph nodes, anaemia)

Developmental Assessment: (motor, social, speech, hearing, vision)

Nutritional Assessment: (height & weight for age, hair & skin signs)

Emotional Assessment: (ask about withdrawal, tantrums, crying, school performance, anger)

Happy, content (green) Prognosis: Terminal Nurse Signature:

Coping but elements of stress (yellow) May improve with treatment Date 2

Very distressed (red) Chronic life-limiting

Pain at initial assessment:

Use the scale below to better estimate the level of the pain the child is experiencing:

Where is the pain? Shade the areas where there is pain & put score out of ten

No pain HIV information:

Mild-moderate pain

Severe pain

Pretest Counseling: Date HIV status: Positive Negative

Where Date of test Yes No Yes No Yes No

Does the child know his/her status Is the rest of the family aware of patients status? Is the patient attending a support group? Which support group? Antiretroviral Therapy Adherence training started: Adherence training finished Date ARVs were started: Date 3

Date Date:

CD 4 Social assessment Housing: Food: Clothing: Mother: Father: Good Plenty Good OK Sometimes no food Has basic clothes Alive but sick Alive but sick satisfactory Poor Often misses meals Not enough clothes to keep warm Not present Not present not coping Died Died

Alive & well Alive & well

Primary caregiver: loving & responsible

Financial resources: well resourced adequate but could become a challenge if there is a crisis inadequate for basic needs Transport: family has a vehicle, transport always available reliant on public transport but can get emergency transport too no transport services or no money for transport Easily accessible- clinic nearby Average access, reasonable level of care Not accessible (too far away or poor healthcare facility) No abuse Suspicion of abuse/neglect Confirmed abuse/neglect

Healthcare

Safety:

safe environment Elements of concern about the environment but not life threatening unsafe living environment posing a threat to survival Documents & Grants Child has the following: Birth certificate Care Dependency Grant Child Support Grant Foster care grant

Spiritual background Does the family have a faith? How important is their faith? Does the family go to church regularly? Would you like spiritual support from our chaplain?

Cultural background- uses traditional healers? Yes/No

Other Children in household

Name of child Age
Gender

CSG? Yes/No

Birth cert? Yes/No

ID number

Genogram: Male Female Died

This is the patient (Female)

This is the patient (Male)

CONSENT & INDEMNITY FORM I, give consent for Ingwavuma Orphan Care to care for (my child). I agree that Ingwavuma Orphan Care will not be liable for any personal injury, loss or damage which my child may suffer as a result of my being cared for by a member of the IOC care team including medical, nursing, home based carers and volunteers. Relationship of person signing consent to child:. Signature.. Date . Witness signature. Witness name

Checklist: Caregiver informed about: Patient & Child Rights Name of caregiver Name of professional nurse Care available from IOC Date Date Date Date Initials Initials Initials Initials

Patient & Family Education: (tick and put in the date whenever you do education) Using gloves/plastic bags Safe waste disposal Hygiene Oral rehydration fluids Healthy nutrition How to take your medicines Bed bathing Dressings Pressure Care Mouth Care Pain & symptom relief Date Date Date Date Date Date Date Date Date Date Date Date Date Date Initials Initials Initials Initials Initials Initials Initials Initials Initials Initials Initials Initials Initials Initials

Care Plan- nurse to fill in

Dat e Problem/need Care Plan
Expected date to achieve goals

Sign Dat e

Evaluation of intervention

Sign

Dat e

Problem/need

Care Plan

Expected date to achieve goals

Sign Dat e

Evaluation

Sign

Dat e

Problem/need

Care Plan

Expected date to achieve goals

Sign Dat e

Evaluation

Sign

Date

Progress notes:

Signature

Date

Date

Date

Date

Date

Discharge record
Patient on hold (not seen for over 3 months): Date Reason Date Reason Date Reason

Patient discharged Date Reason

Patient died Date Details (where?, funeral arrangements etc)

Bereavement counseling doneDate Notes