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    Under 2 Months Clerking Sheet JKNK 2020

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    Syakinah Sabudin
    This document is a clerking sheet for young infants under 2 months old used at JKN Kelantan in 2020. It includes sections to record the infant's identification information and medical history, examine for general danger signs and high risk criteria, note diagnosis, and create a treatment plan. Physical examinations must check for conditions like low temperature, fast breathing, poor hydration, and infection signs, which require consultation or referral if present. The sheet provides guidelines for assessing young infants and documenting the visit.

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    Under 2 Months Clerking Sheet JKNK 2020

    Uploaded by

    Syakinah Sabudin
    160 views3 pages
    This document is a clerking sheet for young infants under 2 months old used at JKN Kelantan in 2020. It includes sections to record the infant's identification information and medical history, examine for general danger signs and high risk criteria, note diagnosis, and create a treatment plan. Physical examinations must check for conditions like low temperature, fast breathing, poor hydration, and infection signs, which require consultation or referral if present. The sheet provides guidelines for assessing young infants and documenting the visit.

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    This document is a clerking sheet for young infants under 2 months old used at JKN Kelantan in 2020. It includes sections to record the infant's identification information and medical history, examine for general danger signs and high risk criteria, note diagnosis, and create a treatment plan. Physical examinations must check for conditions like low temperature, fast breathing, poor hydration, and infection signs, which require consultation or referral if present. The sheet provides guidelines for assessing young infants and documenting the visit.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    160 views3 pages

    Under 2 Months Clerking Sheet JKNK 2020

    Uploaded by

    Syakinah Sabudin
    This document is a clerking sheet for young infants under 2 months old used at JKN Kelantan in 2020. It includes sections to record the infant's identification information and medical history, examine for general danger signs and high risk criteria, note diagnosis, and create a treatment plan. Physical examinations must check for conditions like low temperature, fast breathing, poor hydration, and infection signs, which require consultation or referral if present. The sheet provides guidelines for assessing young infants and documenting the visit.

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    © All Rights Reserved
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    Clerking Sheet For Young Infants (< 2 mths old)

    JKN Kelantan (2020)


    2
    Visit : 1st / 2nd /3rd / 4th
    Name: RN: Date/Time:
    Birth date: Age: ......month......yrs
    Weight: kg Height : cm COH : cm G6PD :  Negative  Positive
    Immunisation Status:  Complete  Incomplete. Pls state...................................................

    Chief complaint:

    HOPI :

    PMH :

    MUST ASK: presence of any GENERAL DANGER SIGNS below, need URGENT consultation or referral.
    Please (√) if present.
    Infant NOT able to feed
    Feeding poorly
    Diarrhea with signs of dehydration
    Convulsions during this illness

    PHYSICAL EXAMINATION : MUST LOOK FOR HIGH RISK CRITERIA


    Presence of any high risk criteria, MUST consult or referral. Please (√) if present.
    HIGH RISK CRITERIA

    Temperature ……………………….. C Must admit if present !


    Less than 35.5C
     37.5C or above

    Respiratory Count respiratory rate(in one minute)……………./min


    ≥ 60/min (tachypnea)

    Signs of Respiratory distress :


    Grunting
    SPO2 ………………….. % Nasal flaring
    Subcostal/intercostal recession
    Chest Indrawing
    SPO2 <95%

    Infant movement  Not moving at all

    Adapted from World Health Organization (WHO)


    JKN Kelantan (2020)
    Active (Spontaneous /strong movement)  Fairly active; weakly move after stimulation

    PHYSICAL EXAMINATION : MUST LOOK FOR HIGH RISK CRITERIA


    Presence of any high risk criteria, MUST consult or referral. Please (√) if present.
    HIGH RISK CRITERIA 2
    Hydration Status Sunken eyes
    - BP ……………/………….. Poor skin turgor
    - HR …………….bpm HR ≥ 160/min
    (normal average 120/min) CRT≥2 secs
    - Cap refill time: ….……..secs Sunken anterior fontanelle
    Bulging anterior frontanelle

    Signs of umbilical infection (eg. redness/pus discharge)


    Sign of infection
    Multiple Skin pustules
    Infant weight gain (estimation : 800gm
    to 1000gm in a month ) Poor weight gain?
    Birth Wt: ………..gm
    Current Wt:………..gm

    OTHER NON CLINICAL INDICATION TO Logistic / transport problem


    CONSULT/REFER: Multiple visits to clinic during this illness
    Visit after midnight
    SYSTEMIC EXAMINATION
    GENERAL EXAM : Pink / pale / jaundice
    CVS : LUNGS :

    ABDOMEN : CNS:

    CNS :

    OTHERS

    DIAGNOSIS :

    Danger signs Present Absent


    INVESTIGATION RESULTS :
    Blood sugar :
    (if indicated)

    Adapted from World Health Organization (WHO)


    JKN Kelantan (2020)
    PLAN: ADVISE WHEN TO RETURN IMMEDIATELY IF:
    - Feeding poorly - Feels unusually cold
    - Not able to feed - Reduced activity
    - Becomes sicker - Fast breathing
    - Develops Fever - Difficult breathing
    FOLLOW-UP PLAN (between 2 to 3 days ) * To give Home Advise Note when discharge *

    Doctor’s Name & Signature

    Adapted from World Health Organization (WHO)

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