Name of the medical form | Name of the section on the medical form | List of the fields |
---|---|---|
Hospital registration card (Green card) | Patient details section | Patient ID, name, DOB, age, sex, date of registration, time of registration, occupation, tribe, religion, place of birth, current address, patient phone number, next of kin name, and phone number |
Triage section | Date, time, and nurse name or signature | |
Patient clerking and compulsory clinical documentation sections | Date, time, grade, name of doctor, contact of doctor, signature of doctor | |
Surgical admission folder (yellow folder) | Cover page | Consultant name, patient ID, name, DOB, age, sex, date of registration, tribe, religion, place of birth, current address, patient phone number, next of kin name and phone number |
SLEWS | One entry for each shift | Date, time, name, and signature of designated person, all 6 vital signs (respiratory rate (RR), oxygen level (%), temperature, blood pressure (BP), pulse, alert-verbal-pain-unresponsive (AVPU) level, SLEWS score, and the time and name of doctor that has been called |
Nurses daily report | Compulsory heading fields on each page | Patient ID, DOB/age, sex, name |
Application of Nursing Documentation Framework (a new framework to be introduced by this project), to be completed on each shift | Date, time, signature, and name of designated person; quality note recording under a set of agreed headings (to be determined) |