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)