Peadiatric Medical Assessment

8/3/2019 Peadiatric Medical Assessment

1/18

Ingwavuma Hospice & Orphan CarePO 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: First Name:

Date of Birth or Age: ID number

Isigodi: Gender: Male / Female

Family DetailsPrimary Caregiver:

Relationship to patient:Age of caregiver: Gender of caregiver :

Legal guardian:

Relationship to child:

CARES Score: (write in new level only when the condition changes)

Date

Level

Level 1: All greenLevel 2: Any yellow, some green, no red

1

File Number:


2/18

Level 3: Any red

Medical assessment- (to be done by nurse)

Immunisations up to date?: Yes No

Current Diagnoses:

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 Coping but elements of stress Very distressed(green) (yellow) (red)

Prognosis: Terminal May improve with treatment Chronic life-limiting

Nurse Signature: Date

2


3/18

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 Mild-moderate pain Severe pain

HIV information:

Pretest Counseling: Date Where

HIV status: Positive Negative Date of test

Does the child know his/her status Yes No

Is the rest of the family aware of patients status? Yes No

Is the patient attending a support group? Yes No

Which support group?

Antiretroviral TherapyAdherence training started: DateAdherence training finished Date:Date ARVs were started:

Date

3


4/18

CD 4

Social assessment

Housing: Good OK Poor

Food: Plenty Sometimes no food Often misses meals

Clothing: Good Has basic clothes Not enough clothes to keep warm

Mother: Alive & well Alive but sick Not present Died

Father: Alive & well Alive but sick Not present Died

Primary caregiver: loving & responsible satisfactory not coping

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

Healthcare Easily accessible- clinic nearby

Average access, reasonable level of care

Not accessible (too far away or poor healthcare facility)

Safety: No abuse Suspicion of abuse/neglect Confirmed abuse/neglect

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 Child Support Grant

Care Dependency 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

4


5/18

5


6/18

Other Children in household

Name of child Age Gender CSG?Yes/No

Birthcert?

Yes/No

ID number

Genogram:

Male Female This is the patient (Female) This is the patient (Male)

Died

6


7/18

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 damagewhich my child may suffer as a result of my being cared for by a member of the IOC careteam including medical, nursing, home based carers and volunteers.

Relationship of person signing consent to child:.

Signature.. Witness signature.

Date . Witness name

Checklist:Caregiver informed about:

Patient & Child Rights Date InitialsName of caregiver Date InitialsName of professional nurse Date InitialsCare available from IOC Date Initials

Patient & Family Education: (tick and put in the date whenever you do education)

Using gloves/plastic bags Date InitialsSafe waste disposal Date InitialsHygiene Date InitialsOral rehydration fluids Date InitialsHealthy nutrition Date InitialsHow to take your medicines Date InitialsBed bathing Date InitialsDressings Date InitialsPressure Care Date InitialsMouth Care Date InitialsPain & symptom relief Date Initials Date Initials Date Initials Date Initials

7


8/18

8


9/18

Care Plan- nurse to fill in

Date

Problem/need Care Plan Expecteddate toachievegoals

Sign Date

Evaluation of intervention Sign


10/18

Date


Sign Date

Evaluation Sign


11/18

Date


Sign Date

Evaluation Sign


12/18

Date Progress notes: Signature


13/18

Date


14/18


15/18

Date


16/18

Date


17/18

Date


18/18

Discharge record

Patient on hold (not seen for over 3 months):DateReasonDate

ReasonDateReason

Patient dischargedDateReason

Patient diedDateDetails (where?, funeral arrangements etc)

Bereavement counseling done-Date

Notes