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RF_COM_H_13_SUDHA
CC-ORDINATING AGENCY FOR HEALTH
PUNNING.
C/45 SOUTH EXTENSION - PART II
NEI DELHI - 110049.
April 23, 1973.
Dear Friend,
*7
Subject: Explanatory Brochure for
patient retrained health records.
The enclosed draft of thebrochure on the records is
long overdue but we need your comments on it before we got
it printed. The illustrations are much better than the°copies
done on these stencils. There will be a cover with
illustration.
Please submit
jrour comments by 15th May . J-JUJ'UllU
--- I J) 1/11
Beyond 15th
May, we would find it difficult to incorporate your suggestions.
We would- appreciate your comments on
1. Clarity of meaning.
2. Spelling.
3. layout.
4. Content and factual corrections.
5. Any other comments.
As for the patient retained health records you will be
interested to note these developments.
1. Leprosy and eye card added to original sot
discussed at Delhi.
2. Patient retained health records can servo as
study cards, clinic retained, in a domiciliary
programme where it is desired to put say 10% of
the population served under intensive study.,
and where the clinic is attended daily by staff
from hospital.
3, Duncan Hospital (WO bods) at R ,xaul has converted
all of its busy outpatients department (16O patients
daily) to patient retained health records (including
leprosy)
4. Only fully prepaid orders can be accepted at present.
5. Strenuous efforts are being made (and many of you
have helped in this ) to translate the cards into
other languages besides English, Hindi a,nd Urdu,
now that this Community Health Section has been
set up in CAHP, Delhi and nearer more printing
facilities.
Sincerely,
/•
Murray Laugesen.
Community Health Section.
J
CONTENTS.
SECTION
1.
Patient Retained Health Records mean better
health care.
2.
Why Patient Retained Health Records ?
3.
The Morley Child Health Record - 0 to 6 years - (HR 1)
4.
Health Record - Mother - (HR 2)
5.
Health Record - lungs -
6.
Health Record - Adults and School children - (HR 4)
7.
Leprosy Record
8.
Health Record - Eyes - (HR ?)
9.
Identification - Immunisation Card (HR 9)
10.
Clinic Retained Proformas for use with Patient
Retained Health Records.
(HR 3)
(HR 5)
WHERE TO OBTAIN THESE HEALTH RECORDS
Community Health Department (attention Dr. V. Benjamin)
C. M. C. Hospital,
Tamil, Tqlegu, Malay3lam- Kannada, with
Vellore, Tamil Nadu:
some English on each carci.
Community Health Section,
Co-ordinating Agency for Health Planning (CAHP)
C z45 South Extension, Part II
New Delhi - 110049:
Hindi, Urdu, Punjabi, Nepali, Marathi,
with some English on each card.
CAHP will also answer enquiries on:
1.
2.
3.
4.
5.
Cards in other languages in preparation.
Clinic retained record sheets.
Sets of explanatory slides (HR 8)
Supplies of this brochure (HR 6)
Additional records in this series. A record for School children
(HR 10) is under consideration.
PRICES:
(delivered to the nearest railway station)
HR 1, 2, 3, 5, 7:
HR 4:
HR 9:
HR 6:
Set of HR 1-7
30 paisa each, including plastic bag & sales tax
25 paisa
10 paisa
Re. 1/Rs 2/- VPP
Section 1:
PATIENT RETAINED HEALTH RECORDS MEAN
BETTER HEALTH CARE.
These records are designed to encourage high standards Cx
health care, while serving large numbers of people. They prcdi io c
the best results however, only when used by a team of permanent
staff.
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One person to irrinimise
One person to register
and weigh the patient.
/f
rs
and one person to treat anaeiiia
-2-
Sec.1-2
tiU
tip
One person to diagnose
and treat
V
I
one person to dispense
others to give health education
and family planning
‘•^Fx/A
Such teams can be formed from present staff in outpatients
departments, and dispensaries.
SECTION 2.
WHY PATIENT RETAINED H&iLTH RECORDS ?
P.iTIENT RETAINED RECORDS ARE SELDOM LOST.
(
The card is of bright colour (yellow for under fives, green
for antenatals, pink for T.B. patients, and blue for others),
It
is 10 inches (25 cm) long when folded, and is kept in a strong
plastic envelope.
It is issued to the patient, with instructions
to bring it for every visit to the clinic.
Antcnatals must also
be instructed to bring their card at the time of admission to
hospital, or there is a danger of the card being forgotten in
the panic of rushing to the hospital when labour begins.
Illiterate people who have little paper in the house, seem
to value these cards more than the educated patients who are
often the ones who forgot to bring their cards.
Patients find
that they get seen and treated faster when they have the health
card in their hands than when without it.
Even if patient
retained records are occasionally left behind, they are very
seldom lost permanently. (A quick check of most medical records
department files will reveal that after 5 years at least 2% of
records are permanently missing).
When used in conjunction with hospital retained record
system, the patient retained card can act as the identification
card for the hospital number system.
KvTIENT WHINED RECORDS ARE EC01WICAL.
These health records with plastic envelope cost 30 paisa
per patient to begin with, while registration clerk’s time costs
another 5 paisa per patient visit.
This compares favourably
with the cost of hospital records systems, many of which cost
several rupees per patient served.
Some hospitals therefore are
changing all outpatients on to patient retained health records.
I
They then have staff available for more useful work such as
weighing children at the time of registration.
PaTIENT RETAINED RECORDS SAVE TIME.
The doctor’s assistants using the health cards, can easily
carry out the health checks and tests before the doctor sees the
patient.
The weight graph on the child health card, and the
I
Sec.
columns on the antenatal card give the. doctor most of-the Information
he needs. He is then able to quickly assess the patients and decide that
protein supplements are needed , or immunisations, or anaesnla treatment/ etc.
Such efficiency and speed are essential if route health, care is to be given
to large numbers of patients. Unless a comprehensive health document is used
either fewer patients must be seen carefully.■, or large numbers are seen and
treated superficially only.
pATijg^ .waiiw
wwjh
GAimg encowge
a high
standard
care
.
When children are seen without a weight graph being made, most malnutri
tion will not be diagnosed.
In India, marasmus which has no special clu<?s
to alert the doctor, is so much more common than kwashiorkor with its
clinical signs.
Without diagnosis of malnutrition we are unlikely, to treat
other illness completely successfully
We alBo miss an important cause of
prevantable intellectual ’stunting1.
The Morley type weight graph is easily
filled in by the doctor’s assistants, as it is not necessary to calculate
age each time the graph is filled in.
Other types of graphs are complicated
to complete, arid are likely to be neglected.
PATJ:W
RECORDS ARd Ag mGJlLY KOBTLE AS ..THE PATIW3.
’Jyon (1971) found that in Punjab villages, 80/ of first boras were
delivered outside the husband’s family home. For second deliveries 36/ and
for third, 2.4/ migrated. often vrith young children , to the maternal grand-
mother’s home. For people in Government
service. this cxistcmary ^.gration involves.
long distances, and an antenatal patient in
Bombay may deliver her baby in the Punjab.
tuberculosis and leprosy patients migrate
to many different doctors in the course of
their long illness, and a patient retained
records once again saves the doctor much
time.
vs
To ensure that the
>.
To be any use the re coni must
go vn th the patient for
delivery.
Sec.2-3
health card is carried by the patient, the patients and staff must
be educated to value them, and relatives must bo warned that in
the panic of rushing a patient to hospital, they must remember
to bring the card also.
HEALTH Cards iiRE USEFUL FOR HOME BASED HEiiLTH G.JIE:
The health card forms a natural talking point and personalised
health teaching aid wherever the auxiliary nurse makes a homo visit.
The child’s name already on the card makes introduction easy when
the nurse calls.
HExiLTH CnRDS ARE USEFUL IN RES.iL'iRCH.
These health cards have been followed up to remote vi11ago?
on a big scale in Uganda, using students in their vacation, on
bicyle (Moffat 1969).
They can be used to document the age
weight incidence of disease, investigations of birth interval.
response to feeding programmes and protein supplements, using
master cards on the doctor’s desk.
HE.\LTH C/iRDS C/lN BE COMBINED WITH THE NUMBERING SYSTEM OF MEDICAL
RECORDS.
If the health card is used in mobile clinics a separate
block of numbers is allotted, and if the patient is admitted he is
gitfen the same number on his hospital retained records.
A rod
inked ticketing machine for numbering walking records is useful.
The main aim is to avoid giving two numbers to any patient the method of doing this varies from hospital to hospital,
HIT LENT RETAINED RECORDS ALLOA EASY REFERRAL TO AND FROM THE
CENTRAL HOSPITAL.
---------The health card acts as a well documented note of referral.
It can be used by the hospital doctor, to summarise the patient’s
stay in hospital, so that the doctor who referred the patient knows
what was done for the patient.
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The health record serves--as a welj/ documented note of
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fh Tient
retained
words
educa
T-E the patient
for
health
.
With 13 iese record cards, the patient learns what is needed
for better health.
By studying her own record card, and her
child's record card the mother is encouraged to take an interest
in her own health, and in her child’s growth, diet and immunisations.
CHILD HEALTH RECORD. (0-6 Year?)
SECTION 3.
HR 1.
Printed on strong yellow card.
This card was originally designed by Dr. David Morley at Ilesha^
Nigeria in the early slsties, and since then it has helped in the
supervision of the health of millions of children in many developing
countries.
It is being used increasingly in India.
The Government
of Maharashtra is shortly printing such a card for use throughout
the State.
The present version owes much to the work of Dr. VI. Cutting at
Jammalamadugu, Andhra Pradesh.
It includes family planning section.
and dotted lines to allow grading of malnutrition.
This record
takes the child up to sixth birthday, the official age for starting
school in India*
Diet pictures are different for South and North.
THE OUTSIDE OF THE CARD:
IDENTIFICATION PANEL provides the staff with enough information
to avoid mix-up of cards in a busy clinic.
BROTHERS AND SISTERS: This section helps staff get to know the
rest of the child1s family.
There may be a new-born whom the
mother has not brought to clinic.
She can then be persuaded to
bring the baby the following week.
Three or more dead babies, or
seven or more live children in the family, are reason for special
care.
And family size must be known before family planning advice
is given.
PROBLEMS AND TREATMENT: This space is for the doctor or nurse
to note diagnosis, treatment and advice as required.
IMMJNISATIQN BOXES: are used for recording details of the
various immunisations.
The doctor may order the injection by^
putting a small mark in the appropriate box
(a)
r——j POLIO'--
I
♦
I_________
This indicates "Polio vaccine ordered” by the doctor or clintc in
charge.
The nurse giving the immunisation completes the details of date in
the box provided.
0?
P u L I 0
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..
Polio vaccine
was given or.
Sec. 3
-2-
The doctor should see the child before immunisation is given.
to see that he is well enough.
Triple vaccine (DPT) should
not be given if there is a history of convulsions.
Nor should
babies with fever be given DPT.
(c)
i d
P T
CONVULSIONS
In this case, tetanus toxoid can be given instead.
THE INSIDE OF TLIL C.iRD:
REASONS FOR SPECIAL CiiRE are noted so that high risk
babies get special attention, even in a busy clinic.
These
are the groups who need special care :
premature baby - 2.5 kilograms (5i pounds) or less
when first seen
' breast milk stopped before 3 monthsZ
weight not gaining over a 3 month period
failure to add solid food so far, and child now 9 months
of age or more
twins, especially if female
malnutrition - if second or third degree (11° or 111°)
anaemia (under 8 grams Haemoglobin)
serious disease of mother or child, such as paralysis,
tuberculosis, congenital defect needing
operation, and also low intelligence.
mother or father dead, blind, mentally ill, alcoholic
or unemployed.
three or more dead children in the family.
six or more children in the family already^
(These recommendations are based on the community studies of
Wyon in the Punjab;
an analysis of hospital deaths in Ferozepur 4
and experience of over 30,000 patient visits of under fives in
Ferozepur District, Punjab.
Each hospital should however study
its own patients.)
"ROAD TO HEALTH" weight graph - formed by the top and
bottom lines of the weight graph.
With a combination of curative
and preventive care, and correct feeding, most children can
attain this road to health.
Parents respond well to the
reminder that brain growth occurs rapidly in the first year, and
that malnutrition is harmful to the future intelligence of thoir
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The upper weight line is that of privileged children
in good health (95th All-India or 50th Harvard percentile.
called the Harvard standard adopted by the Nutrition
subcommittee of the Indian Academy of Paediatrics).
The lower line of the "road to health" is 80$ of top
/
line, and is close to the Indian average.
But with early
solid feeding most babies weights can attain the road to
health.
The lower most two (dotted) lines are 70$ and 60$ of
top most line, and enable us to classify malnutrition into
degrees of severity, as recommended by the Nutrition sub
committee of the Indian Academy of Paediatrics.
’k
The registration clerk fills in the name and address of the
child, then the month and year of birth in the boxes provided.
But while weighing the child, we ask the mother how old he is.
This serves as a double check to make sure the weight is filled
in at the correct age.
If the child comes in July 1973$ and
the mother says he is almost 2 years old, then today’s weight
lies somewhere in the second half of the second year of life:
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If she comes to the clinic in July 1073, then last September was
in 1972, and the baby was therefore born in September 1971.
The first month ofeach yearly graph io outllned fflore
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birth anniversary month♦
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Now we fill in th© months in the boxes provided till, the month of
today's clinic visit is reached.
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laboratory technician uses a rad pen, and uses the 10 Kg line on the
weight chart &s a W Gms Haemoglobin line (9 K.gm for 9 Gms Haemoglobin, and
so on)*
If routine haemoglobins are done, at least half will be found
anaemic , especially from 4 - 36 months of age.
Routine iron and folic
acid may be given instead of testing*
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Note the improvenient of th® haemoglobin level with treatment.
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This is in picture fo»m*
those to be addisd underlined*
Foods already eaten my be ticked, and
In this way, illiterate mothers may
remember diet advice again given*
Preparation of baby'a first food
(Suji j ragi, potato, banana) should be taught in detail.
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FUNNING:
If male attitudes are being discussed .fill up opposite
the picture of the mips face;
of the woman’s face*
if female methods, opposite the picture
For making this easy turn the card on its side.
Family planning is especially needed when!
1. The shild is about 6 months old and periods are
likely to return soon.
2
x.he mother is about to return to her husband’s
village*
3. When breast reading is stopped.
SECTION 4.
HEALTH RECORD -
H.R.2
MOTHER
(Ferozepur antenatal card).
Colour - light green.
This card is different from other antenatal records in that (l) like other records in this series, it is carried by the
patient herself.
If she is told to take it with her, the record
will almost certainly be available when the patient migrates
to her mother’s home for delivery.
(If records are kept by the clinic, then at least one third of
these records will never be used because the patient has
migrated out for delivery.)
(2) the whole pregnancy is charted against the calendar
months so that the early months are always charted at the top
of the record, and later months below;
and calculation of
expected date of delivery is made much easier.
(3) information is recorded in columns so that by looking
up and down the columns progress can be assessed at a glance.
(4) health education, family planning and immunisation with
tetanus toxoid are emphasised.
.THE OUTSIDE OF THE CARD:
HEALTH EDUCATION:
prevent
Notes on correct diet are included to
anaemia of mother, and prematurity of baby.
Good
hygiene and cord care at birth are described to prevent
puerperal sepsis and tetanus.
Fever after delivery and many
deaths, can be prevented if
the dai washes her hands
repeatedly.
-V
:2:
-2-
Sec•4-2
Educate the family and the dai to sterilise the
knife or scissors used for cutting the cord, to
prevent tetanus.
DANGER SIGNS;
These are emphasised.
The ajm is to alert the doctor and
the patient to possible danger to mother or baby.
The list of
danger signs is based on material and perinatal death statistics
at Frances Newton Hospital, Ferozpore,
However, each hospital
should study high risk factors for its own patients.
Number of Danger Sig^s Present.
Suggested Management
None (no crosses in the red
boxes)
Safe for home delivery, if a dai
who uses antiseptic methods can
be found.
one X patients
Summon skilled help if there is
any delay or complication.
XX patient
Admit to hospital when labour
begins.
XXX or XXXX
This is a high risk patient,
Insist on hospital delivery where there
is skilled obstetrician, and blood and
safe surgery if needed. Admit, this
patient from the village 2 weeks
before term. Keep special care file
on these patients, and with home
visits urge hospital admission. For
those who will not agree, try if
possible, to.have skilled help ready
to goto the patient if needed. To
encourage poor patients in this high
risk group to have the best care,
free hospital delivery should be
assured.
ANAEim - UNDER 9 GMS Wl EMOGLQBIN.
If this is found in the
last month of pregnancy, blood transfusion will be needed in
many patients before delivery.
offered hospital delivery.
*
All such patients should be
>
~3-
-3BLEEDING:
Sec.4-3
This includes bleeding during previous pregnancies,
for such patients may bleed again in this pregnancy.
BABY BURN DE/xD, DIFFICULT DELIVERY, FORCEPS OR CaE&iRELN:
Include here any who had babies who died in the first week after
birth.
Some of these may be saved if the baby gets hospital
nursing care.
HEIGHT:
Small women usually have small babies, and low
g
birth weight means greater risk to the baby. Also, if small
women have ’normal size’ babies, they may have difficult delivery due to disproportion between the baby’s head , and the small
pelvis .
25$ of Punjabi women at Narangwal. Johns Hopkins -
I.C.M.R. Rural Research Project, and 20$ of women in hospital
at Ferozpur, were less than 58 inches (147 cm*) in height.
These women and their babies are at greater risk.
SNELLING OF HANDS OR FaCE, OR DIASTOLIC BLOOD PRESSURE OF
90MM OR MORE:
If diastolic blood pressure is raised at 34 weeks
this indicates severe preeclampsia, needing admission to hospital.
Eclampsia can occur in patients seen the previous week with
diastolic pressure of 85 to 90 mm.
BREATHLESSNESS AND HEART MURMUR, OR COUGH A SPUTUM:
This
includes rheumatic heart disease and congenital heart, bronchi=
ectasis. and tuberculosis.
Sputum lasting 2 weeks or more.
should be tested several times for tuberculosis. Women with
breathlessness and heart murmur should deliver in the hospital.
FIRST BuBY, OR 4 CHILDREN OR MORE, OR AGE 35+
baby may be difficult, as every women knows.
The first
But a woman having
her 5th baby or more can quickly get into difficulty.
Women over
age 35 and mothers'under 18 are also at greater risk..
OTHER: Include twins in this pregnancy.
Also the thin, poor.
underweight woman who may need special care for her baby,
The
babies of such women are v<?y likely to be weak and underweight.
PREVENTION OF TETANUS: is emphasised.
Dates of tetanus
immunisations are recorded in the boxes provided.
tions should be given at one month intervals,.
These injec
The ideal is three
-4-
-4-
Sec.4-4
injections, and minimum is two injections.
The first injection
should start with the first visit, with the second given one
month later.
One booster is given with- the next pregnancy.
Tetanus toxoid protects those who will deliver at home under
unhygienic conditions.
In Ferozepur this was two^hirds of all
antenatal outpatients.
It also protects the baby from neonatal
tetanus.
p \\
Protect the newborn from tetanus by
immunising his mother.
THE INSIDE OF THE CARD:
CALCULATION OF THE EXPECTED DATE
DELIVERY is simple.
The
squares are filled with the calendar months following the last
menstrual period, until the square for the ninth is reached:
Seven days are added.
Example:
L.M.P. 16
A patient attends clinic on
29 January. • Her last
Menstrual period was 1 Ass00
by indigenous calendar. This
converted by tables becomes
16 September.
Expected date of delivery:
Months of gestation
__ 0__________
i
1 ____________
i Nov 7 2 ___________
Sep
j Oct
| Dec j
29 j Jan i
I
Feb
s Mar
' Apr
I, May
I June
<
23 June
3 __________
4 attends clinic
5 _________
__ 6_______ __
7 __________
__ _
8
9 ________
(9 months-l-7 days)
All columns across the card are now filled in opposite- todays date
(29 January).
The instructions in treatment column show that her
next visit is due.in one month.
-5-
-5-
Sec.4-5
In case date of last menstrual period is not known, decide
stage of pregnancy by size of uterus, or date of first
movements felt.
SIZE OF UTERUS:If size of uterus is in advance of dates
we can easily tell by comparing "size of uterus” column with
’’months of gestation”
column.
Gestation.
expected uterine size
3 months
just palpable above symphysis
(or 3rd month completed)
4 months
(or 4th month completed)
-
half way to umbilious
5 months
Just below umbilicus
6 months
Just above umbilicus
7 months
—
8 months +
- Xiphisternum
Half way between umbilicus and
Xiphisternum
VERTICAL COLUMNS for serial recordings of haemoglobin.
blood pressure, weight, for each visit, allow easy comparison.
HAEMOGLOBIN AND OTHER BLOOD TESTS: Krishna Menon, a world
authority on pregnancy anaemia, recommends routine iron and
folic acid treatment from the start of pregnancy.
Anaemia,
he says, is the commonest complication of pregnancy in India,
causing at least 20$ of the maternal dealths.
Iron and iron +
folic deficiencies are the common types (10)
Measurement of
Haemoglobin is eveP more important than measurement of blood
. ,
n x .
(11).
pressure in developing countries.
V.D.R.L. & Kahn tests for
syphilis are expensive and routine testing is done only if a
worthwhile number of positive cases are being found.
Otherwise
these tests are reserved for those suffering repeated still
births.
■
i
A daily tablet of iron and of folic acid
costs less than 3 paisa per day, or Rs.7
per pregnancy.
Sec.4-6
WEIGHT:
The underweight woman who may have an underweight child.
She may be from a Scheduled Caste and is usually poor.
She may be
less than 35 Kg. (77 lbs) before pregnancy;
she may gain 6 Kg
(13 lbs) only during the whole of pregnancy.
At term her weight
is less than 40 Kg (100 lbs).
previously.
She may have had weak small babies
She needs diet advice to eat more, and food supplements
in second half of pregnancy, especially in the last month.
The woman with twins or toxaemias.
fast - more than g kg (1 lb) per week.
She gains weight too
In such cases look care
fully for twins or toxaemias.
However women with twins oh poor
diet may show poor weight gain.
If the clinic does not have
reliable scales, it is better to predict prematurity by questions
about income, caste and diet and previous babies.
And for hyper
tension we can measure blood pressure and for twins we can do
car.eful abdominal examination at 6-7 months pregnancy.
Twin babies
should get food supplements before birth,-besides double dose of
iron and folic acid.
Mother should be persuaded to eat more and
better food.
. EDW:
serious.
Edema of feet in pregnancy in hot climates is not
But edema of face, fingers or abdomen is recorded as -FH-
in this column and as a cross in danger column on the outside of
the card.
PLACE DECIDED FOR DELIVERY:
After assessing the risks, home or hospital delivery is advised.
Distance and transport arrangements to get skilled help are discussed.
Often the patient can go stay with relatives in the city to be near
the hospital in case of difficulty.
If home delivery is decided on, clinic staff can encourage
use of a dai who practises asepsis, use of a clean room and clean
clothes and sheets.
Hospital delivery for the mother with 4 children or more will
make it easy for her to get sterilisation soon after delivery.
Otherwise customs may prevent her leaving home so soon after home
delivery and the tubectomy will not be done.
-7-
-7-
Sec.4-7
FAMILY PLANNING is included as a normal part of good comprehensive medical care.
Only when the woman and her family are sure
of a safe delivery, and a live baby, can they start planning t.hei r
family size.
Good medical care makes family planning acceptance
more likely.
During the antenatal period the woman is more than
usually interested in family planning.
The details of previous
children help in advising spacing or more permanent methods.
FamiXy^planning motivation and persuasion is especiallyneeded for high risk women : (12)
1.
women with four or more children
2.
women with a child still on the breast (too soon)
(too many)
3. women with only one or two years between babies (too fast)
4. women with chronic diseases or with sick or malnourished children
(too sick)
5. women with a marriageable child
(too old)
6. Women with previous abortions (too dangerous)
7. women with twins
(too fertile)
3. women with enough sons.
For women not in these groups, information only is given, without
persuasion.
The important times for giving family planning advice are (12)
1.
at the first antenatal visit for confirmation of pregnancy
(information only is given at this time, unless the woman
is a high risk type.
2.
again at each antenatal visit for high risk cases.
3.
at first visit after baby is born , ospecially if there wasus
an>abortipn or still birth.
4. when child is about 6 months old, or when menstrual periods
are likely to return soon.
5.
if and when breast milk is being stopped or has to be
supplemented.
AFTER THE PREGNANCY the mother uses the same card until the
next pregnancy, when another card is stapled to the first,
The
mother!s card has on it her hospital unit number and her i rnrm.in.isa—
tion and pregnancy history. so it is kept by her permanently.
SECTION 5:
HEALTH RECORD - LUNGS
H.R. 3
(THE TUBERCULOSIS (T. B.) CARD)
Colour - red.
This card was designed in Ferozepur at the request of
Dr. K.S. Gill, a leading general practitioner of Moga.
He wanted
a card which would help the patient to keep up regular treatment.
even if the patient changed doctor several times during the course.
o£ treatment.
The card should help the doctors who treat the
patient in the course of IS months, and should help the patient
to stay on treatment'for the full 18 months,for a lasting cure.
It is used along with the Child Health Card or the Antenatal
Card, if the T.B. patient belongs to one of these groups, by
stapling both records together.
THE OUTSIDE OF THE CikRD:
1.
Previous Treatment is recorded in the special panel.
This
will help alert the doctor to possible drug resistance or drug
toxicity.
2.
Streptomycin Infection Record,
The doctor can see if the
patient has received the streptomycin daily, or twice weekly. as
ordered.
STREPTOMICIN INJECTION RECORD
Injector checks dose and circles date of injection
for correct Month, Please compare with month column
on inside of card by folding card inward to show .
X-ray opposite.
FEB
6
9
4
MAR
:T,23<®5 6 7<^9 w O 12 13 14 _
16 17 4 8)19 20 21 @ 2g 24^26 2? 28(29)30 31
1
15
2 3 4 5 6 7 8 9 10 11 12 13 14
1617 18 1920.21 22 23 24 25 26 27 28 29.30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 1? 18 1 9 20 21 22 23 24 25 26 27 28 29 30 31
12 3
4
5
9 10-77'12 13 14-------------
[ JW 15 16 1? 18 19 20 21 22 23 24 25 26 27 28 29 30 31
This is the result if the patient receives his
streptomycin injections regularly every Monday
and Thursday during February.
The correct month is found by turning the outside of the
card inwards from the right, so that the month column lies uncovered
against the streptpmycin section.
-2-
-2-
3.
Details about the patient:
Sec.5-2
Full, address
will help decide
wither patient should be on tablets with or without streptomycin
injections, and full address should also be copied on to the
special care or high risk file.
This will include sputum positive
patients.
4.
■feevention of T.B. in the Family: The Mantoux test is useful
for preschool children who have not received B.C.G. and who are not
malnourished.
It is best to list all the household members at the
first visit and then see how many will come for checkup.
The
Child Health Card should be made put foi^.11 preschool children
contacts, because poor weight gain on the weight-for-age graph
may suggest tuberculosis.
B.C.G. is given to the children if they
are still Mantoux negative after 3 months..
5.
Concerning T.B: This health education section aims to encourage
completion of treatment - the main problem in T.B. control.
The
patient is encourage^ to prevent further spread of the disease by
bringing contacts for medical examination.
He is instructed to■
burn sputum.
THE INSIDE OF THE CARD:
1.
Treatment Record -
the card allows for 18 monthly visits
until treatment is finished.
through the treatment.
The patient can see hiw own progress
The date of the first visit is filled in
under columns day, month and year.
Then the calendar months are
written in consecutively below this (as for the Baby Card) until
the bottom of the card is reached.
r-x-t
/
T
1 F' A
4J
M
y
It D
“ PR5 |M
I
1
-A i>'Km vl
TT'
.1 -J-Ae/c-- (% cjJ (• i i x
Ko t
e
I6i
yd
■
I >
4
3g;3
I
io
—JI
* tx
__ rrt~H
___
t—1—
lh
TH 3GJ AA/i
-..A
i
'I Y-S* ‘
tYOV'
Vyc ^”
L *C
Vrr-’
Record of a child who did not attend during April.
To avoid overdosing with thiacetazone INH tablets (100 mg)
plus combined INH-thiacetazone tablets are given.
I)
39
X
vV
12 vs
^7
2V X-tn
~
-32.
Sec.5-3
Vertical Colm^ns allow easy comparison of weight, etc from
month to month.
Miniature X-rays can be filed in small envelopes
and stapled to the T.B. Gard in the Chest X-Ray Column, opposite
the correct month.
3.
The columns for the 4 standard drugs allow the doctor to
select whatever regime suits his patient best.
The card may serve
as a prescription, when it is presented at the pharmacy.
If other
drugs are needed, they may be written in the column for symptoms
and effects of treatment.
4.
Number of days drug supply given.
Pharmacy staff fill this
in , because due to lack of cash or shortage of drugs, the patient
may not collect the amount of drug ordered, This record of supply
failure
/ will help clinic staff to unearth the reason at the next visit.
Normally drugs will be packed in 15 or 30 day lots, to last till
the next clinic day.
5.
Drug dosages:
Given at the bottom of the treatment columns,
these allow correct calculation for children’s dosages. (13) It
should be noted that a combination of INH only and INH-Thiacetazcne
tablets is needed to avoid overdosing the child with thiacetazone.
6.
DRUG ALLERGY.
Reactions to all kinds of drugs especially
anti-T.B. drugs should be recorded here.
SECTION 6:
HEALTH RECORD FOR ADULTS AND SCHOOL ^CHILDREN.
(colour:
H.R. 4
light blue)
Like the other health records, this is kept by the patient
in a plastic bag as a permanent "walking record" of his (or her)
health.
It was designed for all those patients not qualifying
for pre-school, antenatal or tuberculosis records, who come for
out-patient care in the hospital or its clinics.
It is also
useful for school medical examinations and disaster medical care.
And. when the "notes” section of the under-fives health record is
full, the reverse side of this card gives ample space for more
clinical notes;
it can be stapled on, or inserted in, that record.
THE FRONT SIDE OF THE RECORD:
The identification panels enable us to call the correct
patient from the waiting crowd.
The registration clerk completes
these panels.
Age and sex: If male, enter age under the male face, if
female, enter age in years under the female face.
PPWttnity or Caste: This we need to know, for the strict
vegetarian may need testing for anaemia, while the poverty of
under-privileged groups may prevent them getting proper health care.
Immunisations:
adults.
These allow for vaccines commonly needed by
Polio is not separately named, because polio is so far,
common only in pre-school children.
Where diphtheria is common
in those five years and over, the ’other’ space can be used for
diphtheria-tetanus vaccine.
Small-pox, cholera and typhoid are
retained for use in disaster situations.
Children and family planning: This remi nds us that good
health care includes the welfare of the whole family.
Big fami lies
usually have poor nutrition and health while the treatment of many
diseases. such as chronic rheumatic heart disease in a'mother, is
not complete without planning of family size.
jjyes and Ears: School children without good eyesight or hearing
may need to sit nearer the teacher, who needs to know which children
are under this handicap.
Children with discharging ears run risk of
tetanus coming through this entry pointso they need immunization.
-.2-
s,ec.6-2
-2-
Breathlessness, cough and sputum: This detects those at risk
from chest and heart disease, and alerts us to test the sputum for
tuberculosis.
Addictions and allergy: Alcohol, opium and bhang (marijuana).
cigarettes and too much food can be mentioned here as addictions
which shorten life or affect health.
deaths;
Alcoholcauses many hospital
also it uses up much of the children’s food money in a
poor home.
Alcohol also makes family planning more difficult.
Allergy includes drug allergy, specially to penicillin.
Other causes of predictable death or shortened life, such as
diabetes or cancer. cari^f present be mentioned in this ’other’
section, but heart and chest disease and addictions and allergy
include most of the predictable causes of deaths, once we exclude
infant and maternal deaths. 4
Instructions to the patient:
The patient is asked to bring
the health record whenever he comes to any hospital or clinic,
by checking the imironisation record, the doctor will see that the
After.an accident/ patient is already protected against tetanus.
Also where the child has had immunisation or other health care
at school, the family doctor and parenus know what has been done.
REVERSE SIDE:
The date column is filled in by the registration clerk, so that
the doctor always knows that the patient has been registered.
The weight is noted each time so that the patient takes
intelligent interest in his own health.
It is the cheapest
objective test of continuing health that is available to every
one.
In school health or nurses health care, falling weight is a
serious sign alerting the doctor to tuberculosis.
Haemoglobin: Anaemia keeps millions in poor health, and anaemia
can be diagnosed quickly and treated effectively at low cost in most
patients.
Problems and treatment: In this section laboratory results can
be written in red to separate them from ths doctor’s writing. The
treatment written here by the doctor can in mobile clinics be used
as the prescription for obtaining medicines from the mobile dispensary.
Example:
Problem.
Treatmnt.
Fever with shivering every 1. Chloroquin
second day:spleen palpable. 2, Slide for parasites taken
1. Oral streptomycin & Kaolin
Diarrhoea with blood
2. To bring stool for teste
pus & mucus
If the patient needs referral to ’■he central hospital, this section
SECTION 7a
THE LEPROSY RECORD.
H.R. 5
The Leprosy Record card has been designed by Muzzafarpur
Leprosy Hospital for use by any hospital or doctor, to .help to
integrate Leprosy treatment into the general Health Services,
and to ensure that patients will continue their treatment regularly
wherever they may be.
Specialist Leprosy Hospitals will obviously
want to keep more detailed records in addition to this patientretained card.
The card has been designed for two years treatment•
to be kept by the patient in a plastic bag.
It is
At the end of the two
years a new card will have to be made and can be kept in the same
bag.
I
Host leprosy patients think that they can only get treatment
in specialised centres.
This card should help them to overcome
any diffidence they may feel about approaching a local practitioner
or Out patient Department for treatment, and will ensure continuity
of treatment.
This patlent-retained record will be as mobile as the patient
with leprosy.
HOW TO USE THE LEPROSY RECORD:
Page 1.
At the first attendance, the details on page 1 are fi11ed in
as far as possible and also the Examination on Admission chart
on page 5.
PROGRESS SUWa RY: This should show any highlights during the
course of treatment withdates o.g.
3.2.71 L. Drop foot' developed
6.6.71 L. Foot ulcer
9.4.73 L. Foot operation
’Became Inactive’
i.e. No increase or decrease in the disease
for at least 2 years and skin smears negative
for at least 2 years.
’Became Disease
Arrested’
After two more years treatment, smears
remaining negative and no new signs.
Maintenance Dose:
All patients are advised to continue)D.D.S.
for a number of years after they have become
Disease Arrested. It would be impractical
to go on making out new cards so it is
suggested that the prescription be written
here and the date of attendance noted.
-2-
3ec.7-2
-2-
Type
In the type box two sets of letters have been
used
Indeterminate
T
D
L
or
or
or
N
N ? L
L
Tuberculoid
Dimorphous or Borderline
Lepromatous
It is suggested that the appropriate letter
is circled on admission and if the. type
changes later an arrow can be drawn to the
second type.
PAGES 2, 3 and 4*
The inside of the card has been laid out so that two years
treatment can be seen at a glance.
A space at the top left hand corner has been left for any
special notes.
In addition to giving specific anti-leprosy treatment.
attention should be given to care of eyes, nose, hands and feet
and also to the general health of the patient, so columns have
been provided for these.
The card
could be taken to the Dispensary
and used as a prescription for these medicines.
No doubt hospitals
and Practitioners have their own standard forms for ordering
•
Laboratory tests. Physiotherapy etc.
Col. 1. Month - this shows the number of months since the
commencement of treatment 1-24.
If t.ie patient takes 2 or 3 months
treatment at a time. or if he misses a month, the intervening
spaces should be left blank, in this way the regularity of treatment
can also be seen.
Col«2« Date - the easiest method is to use a date stamp.
Col. 3:Condition -
Any special remarks about the patient1 s
condition should be made here e.g. Fever, Reaction, Ulcer , etc.
Col, 4: Skin smears - Whenever possible these should be done
at the first attendance.
If lepromatous or Dimorphous type these
should be repeated at intervals to check the effectiveness of
treatment.
Stars have been printed at 6-monthly intervals as a
reminder to the Doctor to check on these.
It is suggested that a
tick be made to indicate when ordered.
-3-
-3-
Sec. 7-3
■SpA.?. 5 ■ Anti-leprosy treatment - The most common treat
ment for leprosy is D.D.S. or Depsone, but if this is not well
tolerated, different drugs may be necessary, so two columns
have been provided.
Col. 6: - Eyes -
It is recommended that Lepromatous
patients have Atropine
eye drops instilled once a month
as the eyes are always affected in this type of the disease
and this will help to prevent adhesions.
In case of obvious
eye infection, more vigorous treatment will be required.
Space is given in the second column.
Col, 7: Nose -
To prevent ulceration and infection
of the nose. some bland oil is recommended e*g. liquid
Paraffin to be applied twice daily.
Col, 8: Ulcers and Physiotherapy divided into 5 parts.
This co.
is
Its
use will depend upon the
facilities available in the
Hospital, but should also be
a reminder to the Doctor to
teach the patient about care of
hands and feet.
The leprosy patient who
cannot fecApajx) must inspect
his feet daily.
Anaesthetic feet need special protection
fr-: vnnotic ---5 in.’ury.
-5-
Sec.7-5
Ba c illaiy Ind ex:
6
5
4
3
= 1,000 or more bacilli in each field
= 100-1,000 bacilli in each field
= 10 -100 bacilli in each field
= 1-10 bacilli in each field.
2 = 1*10 bacilli in 10 fields.
1 = 1-10 bacilli in 100 fields.
negative
= no organisms present.
The bottom line shoK± the Morphological Index (M.l)
whjc h is the percentage of live bacilli seen.
ADMISSION AND SUBSEQUENT EXAMINATION CHARTS: These should be
filled in at the time of first examination and subsequently
if there is any change or at the end of 2 years.
These
charts should show ikhe extent and number of . all lesions.
.Pale patches are
shown by horizontal
lines.
Anaesthetic areas
by vertical lines.
Modules are shown
as small circles.
Thickened nerves are
shown by thick lines
in the appropriate aifea.
I
Other lesions such as lagophthalmios, foot drop.
deformity of fingers etc should be written on the chart.
This chart is important for comparison later as
patients are ofiron unable to remember the extent of their
original lesions or how long they have been present.
PAGE 6:
HEALTH EDUCATION:
This page is printed in the local
language for the benefit of the patient.
It gives simple
directions as to how he should protect himself and his
family, and also tell him the date of his next visit.
■rAuii
Sec*7-<-
If the patient with leprosy must smoke, he
needs a cigarette holder to protect his
anaesthetic fingers ffom burns.
\
t
\
Anaesthetic hands need special protection
from burns to prevent deformity.
IM4UNISATION: At the bottom of the page is a
space for recording B.C.G.
Vaccinations for his family
contacts, thus helping to protect them against Tuberculosis
and Leprosy.
SECTION: 8.
HKiLTH RECORD - EYEf
Colour: green type on green
H.R. ?
card.
This card is for eye surgeons, eye camp teams and general
doctors who see eye patients.
It will give him a clear picture
of the changes in each part of the eye, and save much time for
the doctor and his team.
It was designed by Dr. S, Julius,
MacRobert Hospital, Dhariwal, Punjab, for use by their eye team.
The record is kept by the patient, and so is available
for the doctor, even if the patient changes doctor or place of
consultation.
As with other records in this series, only a
team of workers with the doctor as team leader and teacher
can achieve a high level of caro for large number of patients.
Tensions, visual acuity, visual fields and refraction work can
be delegated, and this card enables the doctor to check the
quality of the work done by his team.
OUTSIDE OF THE CARD:
Identification panels. Immunisation panels, Family
Planning box and reasons for speciaj^are are almost the same
as for the general adult health record.
The main difference
is that there is space to record 6 monthly Vitamin A given to
prevent recurrence of Vitamin A deficiency.
This can be
regarded as an oral ‘’immunisation11 against the disease.
EXTRA NOTES is for eye patients who have illness
affecting other parts of the body or for regular eye patients
who have used up the inside of the card.
REFRACTION:
This section records vision old and new.
far and near, and so if the patient breaks or loses his glasses
he can show this record to the optician and have a new pair
made without having to see the doctor.
Also Government
employees need regular eye checks. conveniently noted in
these boxes.
OPERATIONS DONE: This acts as the summary of past and
present operations done. * The patient takes this record home,
and shows it to his local doctor.
-2-
-2-
Sec.3-2
HEA.LTH ADVICE FOR THE EYES:
Surma contains black granules
which block the punctum and naso lacrimal duct
infection.
and predispose to
Also granules and the rod used for inserting the
surma, cause abrasions of cornea which lead to irifection which
occasionally results in loss of the eye.
Also the rod used may
spread infection from one child to the next.
•Kajil is an ointment applied with the finger, and the
finger spreads infection from one child to another.
For young women, eyebrow pencil is much safer than
Kajil and surma put into the eye.
INSIDE OF THE CARD:
Date - Registration clerk stamp the card here with the
date .
Projection or Visual fields: This is useful in retinal
detachment, prognosis of cataract operations and in space
occupying lesions.
Tensions: In glaucoma, if these fail to respond to medical
treatment surgery will be necessary.
EYE DLVGRAMS: These record, in picture form, the changing
-pattern of the disease from visit to visit. and the exact shape
and size and site of the lesion.
Corneal ulcer or opacity.
type of iridectomy, size and shape of pupil extent of hypopyen
or hyphaema, limbal follicles in healed trachoma and xerotic
spots, can all be shown by recording it in writing on the
appropriate line, with an arrow to the lesion drawn on the eye
diagram.
Blood pressure, urine, Blood and other tests: These are
useful for preoperative check-ups and for systematic diseases
affecting the retina.
Treatment:
This records moaical and surgical treatment
given or prescribed at each visit.
Just as important it records
advice given.
Next visit the doctor checks if the advice given
was followed.
The drugs written here will be enough for special
eye team dispensaries, but for general pharmacies, the prescription
should be also written in full on a separate script.
ec, J-3
CLINIC RETAINED TxiLLY SHESTS, for use by eye teams using
those patient retained records. are available from Eye Department, MacRobert Hospital, Dhariwal, Punjab.
/
There are separate
tally sheets for registration, refraction, eye pharmacy,
eye diseases, etc.
These simplify collection of statistics
of work done.
k
H.R.?
TMMJNISATION - IDENTIFICATION
SECTION- 9
Colour red, on stiff card. in strong plastic envelope.
It is
This card is useful for popularising immunisation.
used in hospital out patient departments, where patient reuaxned
health records are not used for all patients, but where some record
is needed for the patient, in his hand, of the immunisations given.
As many hospitals already issue the patient an identification card
giving patient's name and hospital number, this aminunisation
record can be put on the back of such a card, and serve a double
purpose.
The same card, without number being added, can be used to
■ immunise relatives and friends of the patient, thus making follow
up immunisation at branch clinics or sister hospitals possible.
on the basis of the card given to the patient.
In Schools the teacher or student fills in the student's
name on the card, after immunisation and gets date written m
correct immunisation box.
The teacher keeps all immunisation ■■
cards until the course is completed.
Then the child takes the
t-.
card home for parents to keep.
In House to house cawaigns thi? card is_ cai-ried in tae
worker's cloth shoulder bag, and pre-nwnbered cards keep track
of the amount of work done.
The same cards are asked for at each
visit tillthe course is finished.
Note:
/
This card is small and much more easily lost than
the other larger patient retained health records in
this series. But it is also much cheaper.
The plastic for the envelope for this card should
be at least 3J0 gauge, as for the other records.
When a person carrying this HR 9 card, needs another
card in this series, such as HR 2 mother’s card "’n
the case of pregnancy, the HE 9 card is torn up,
after transferring name, number, and any immunisation
given, on to the new card.
Where all outpatients are given patient retained hoc1th
records, there is no need of this small card.
.Reverse side.
fi-------------------------------r
Front side.
Francis Newton
pital
Hospital,Ferozpur
ToT"
li Write date giien.
rasie
RAM LAL
Small Pox
z ib er
9801
Tetanus Toxoid
.x. Fly bring this to hospital each
u..cc After any accident show this
■-■■J. to the doctor.
i-±
j
L__--------------------
TAB
! Cholera
H69 J-G/
W d’
IX
di i
I
I
’I
--------------------- !-------------------------------------
___ i
1°%I
I
SEC ION- 10.
CLINIC RETAINED PROPOJMiS FOR USE WITH PATIENT
RET/iINED HEALTH RECORDS.
Everyone asks, how do we keep statistics if the record is
This is no problem if we write the patient1 s
in the patient1 s hand ?
number only, in the correct column of a duplicated foolscap
proforma.
Each clinic worker keeps her proformas on a clip board.
Total's, are done at the end of each day.
Samples of these useful
proformas can be obtained from Community Health Department,
Frances Newton Hospital, Ferozepur, Punjab.
There are 'separate proformas for -
attendance
(with separate columns for under fives,
antenatals, TB, and others, and,for
first and revisits).
Immunisation (with separate columns for 1st, 2nd
3rd DPT, Polio and tetanus toxoid,
TAB etc)
Anaemia
(with separate columns for those
found to be anaemic and those to
whom tablets given; by age group)
Pharmacy
(with separate spaces for each drug
and for amount given, all drugs
prepacked and prc».priced.)
Diseases
tally sheet
(allowing calculation of age
incidence of diseases seen and .
collection of statistics for
Government.)
These sheets are handed in or posted in to the office of
the doctor in charge.
From these sheets ample statistics .are
obtained for writing all necessary reports of work done and
supplies consumed.
ATTSNDzxNCE RECORD
Name of clinic:
SHARINWALa
Dated:
30.6.73
Put circle round numbers se^free.
|
------------- :----
■
10-2 yrs
1.
U3 ------—
2492
-X2-_L 2493
„3.
2503
£4.
2504
3-5 yrs. 6-|4 yrs.
2494
• W—
—,.
2495
II..
.
,
«M._
2496
Tuberculosis.
_
I
Antenatal. Tetanus
Toxoid Other
only
. 249^
2499
-2501
2500
2502
1
J Total
all
-2-
Sec.10-2
IMMJNISxiTION RECORD.
Name of Clinic.
SHxl RMa Lx
Date
30.6.73
Instruction:
record patient’s number once for each vaccine.
1.
(Booster.
2.
.3.
1. 6249 2424 11349
1
tI
2. S 24921
_
1.|
2321
Polio.. . Oral
2. I
6249 1949
;
3.
I
4.
1349
5.
Booster
w___
1295
2492 2424
HQ
T--
2493
...........I
iiNiiEIlLk RECORD.
Name of Clinic.
SHARTNVJALa
Date
30.6.73
H* patient receives two packets of the tablets, write his number twice.
Age group
(years)
0-5
Hb under
Hb
6 Gms
6-9.9 Gms.
1. 6243
Hb
10 Gms +
Hb not
Iron-folic
recorded under 5(30)
today
antenatal (60)
6524
6243
2.
1
'ther
.reatment
>r remarks
6524
3.
4.
PHuRlWY RECORD.
Name of Clinic:
Date
SHiiRIMUIA
30.6.73
1. Write Unit Number of patients receiving drugs.
2. Those receiving the drugs free have their
SOLD
FREE
numbers circled.
3. Keep this form on clipboard.
4. If patients receive 2 packets write number"
No. dash
No • •’ Value Selling)
twice.
used reed.
usedlRs. p. Rate
I
A & D
Vitamins
(10 Caps)
TABLETS.
\4295!
Aspirin
75 mg (10) (2424) (2424;
ASA
jAspirin)
300 mg(20)
1t
4294
4294
I
267B
2572
1
i
- -- -
i 1
0.50
j
i 2
------ -
r
0.50
i
2
0.50
2
1. 00
Chnn H I'i.’XCHILD HEALTH AND WEIGHT CARD FLANNELGRAPH
Prepared by:
Audio - Visual Unit, C.MtC. Hospital, Vellore, Tamil Nadu.
In co-operation with;
Nutrition Education Unit, C.S.I. Hospital, Jammalamadugu, A»P,•
Introduction.
The use of parent-retained Health and Weight Cards
For Under 5 Year olds has been shown to benefit th^' child and
family by
1. Promoting adequate growth.
2. Advising on correct feeding.
3. Educating about full immunisation.
4. Indicating reasons for special care.
5. Recording important illnesses.
6. Encouraging family planning.
These cards can also greatly facilitate the work
of the staff in a Young Children’s Clinic.
The flannelgraph will help to teach staff and
parents to understand and make the best use of the weight cards.
Hints on use of the Flannelgraph.
1. Cut out the figures, dots and words from the printed
flannel. Keep these flat between two pieces of
thin board.
2. Secure the background flannel of the weight graph
onto a board. This should be firm so it will
not collapse during the demonstration; it should
slope so the appliques (figures, dots etc.) will
not fall off; it should be displayed so that every
one in the group can see it.
3. Arrange the pieces of flannel for application in the
correct order so that you will not have to search
or fumble during teaching.
4. Practise before hand so that;
You are sure of the sequence of teaching.
You know where you will place the dots, words
and figures, and
You can give the commentary fluently and
confidently.
5. Keep the teaching moving by adding new dots, figures
or words to the flannelgraph in a logical sequence.
6. Do not clutter the background with too many appli
cations at a time. Clear off the previous
illustrations before starting on a new topic.
7• Teach about only one major aspect of the weight card
at a time. A short, concise lesson is more
effective than a long, dull lecture.
community
health
cell
47/1,(First FloorlSt. MarksRoad
BANGALORE-660 081
5S
2
=
The Weight Card and FJ.annelgraph are particularly valuable
when teachirp about iI, Achieving adequate growth,
lit Correct feeding.
III. Reasons for special care.
IV. Immunisation to prevent disease.
V. Family Planning as related to family health.
Teaching can conveniently be divided under the
five headings indicated by the Roman numerals, but the
topics are interdependent.
I* Adequate Growth and Development.
Place the dots on the weight graph at monthly
intervals to show a good gain; for example;
3 Kg. at birth,
6 Kg. at 5 months,
9 Kg. at 12 months, and so on.
♦
X
Point out the two lines that curve upwards across
The upper represents the average weight of a
the chart.
chart
well-nourished and medically protected Indian child. The
lower represents the average weight of an Indian village
which can be referred
<’
child. Together they form a channel
to as The Road to Health, Demonstrate how the weight dots
of a healthy child climb up this road and if the weight
dots fall below the lower line we may say llthe child has
fallen off the ’Road to Health1 and needs extra feeding and
careM*
A healthy child is one who gains weight regularly
and well• If a child is not gaining regularly, extra advice,
care and help are essential.
Place the pictures of the Correct milestones of
development above the weight line at appropriate ages; for
example;
r
Infant lifting head and chest
Infant sitting alone
Infant standing supported
Infant standing alone
at 3 months Picture No.11)
at 7 months No.12)
at 10 monthsiNo.13
at 12 months(No.14
Illustration (i) Adequate Growth and Correct Development.
In Teaching emphasize that
a)., A steady gain is more important than the actual
position on the weight graph.
b) . Regular attendance to check growth and receive
advice is important.
c) i Achieving adequate growth is the best way to prevent
malnutrition.
II. Correct Feeding.
Correct feeding is essential in order to achieve
adequate growth and development.
Place the pictures of the foods below the growth
curve starting with the mother breast feeding the baby, and
introducing the others in a suitable sequence after 6 months.
=
3
=:
Mother breast feeding infant (No. 1)
Tumbler of congee (gruel) with feeding cup (No.2)
Egg (No. 8)
Banana (Plantain) (No. 4)
Plate with rice dhal and greenleaf curry (No.9)
Cow, representing cattle mil* (No. 3)
Groundnuts (Peanuts) (No. 7)
Meat (No. 6)
Suitably prepared.
Fish (No. 5)
At this and at other stages in the Flannelgraph
demonstration it is good to get the staff or parents to
participate. For example they can each be given a flannel
picture and later asked to say what it representsf why it
is important and then they should come forward and fix the
picture on the flannelgraph.
Illustration (ii).
The Right Foods for Full Growth.
Feeding instruction can be considered in 3 periods
1 st. Birth to 6 months.
Milk is very important, and plenty of breast milk is
best (Picture No.l). If mother’s milk fails, adequate
amounts of buffalo or cow milk should be given (No. 3).
possibly supplemented by a local gruel (congee) (No. 2).
Feeding with powdered milks should not be encouraged
unless the parents can understand the problems involved
and have facilities for sterilising bottles etc.
2nd.
6 to 24 months•
Milk, preferably breast milk, is still important
but other foods must be introduced and increased in
amount. Start with a local gruel (Congee) (No.2), soft
cooked egg.(No.8), and ripe banana (No.4). Rice with
dhal (lentils) and green leafy vegetables (No.9), and
other local staples should be given. Add other protein
containing foods suitably prepared for a small child;
groundnuts (No.7), and if acceptable, meat (No.6) and
fish (No.5).
3rd.
2 to 5. years.
Staples, preferably a variety of them, will now
make up the main bulk of the diet. As growth is still
continuing rapidly, body building foods (Proteins) and
protective foods (vitamins and minerals) are still importtant in addition to energy foods*
III. Immunisation.
Many serious infectious diseases of childhood
are preventable by correct immunisation.
Place dots on the flannelgraph to represent a
satisfactory growth curve and against this attach in appro
priate places the names, pictures and syringes representing
the immunisations.
=
4
=
B.C.G. Syringe at birth (No. 16)
Smallpox vaccination in the 1st month (No.15)
D.P.T. Triple.innoculationi in 2nd 3rd and 4th
O.P.V. Polio immunisation u months, three syrinqes
(No. 17)
Measles vaccine, in 9th month, when available
in India* additional syringe (No. 18)
D• Triple J booster at about 18 months,
O.P.D. Polio II additional syringe (No.18)
Illustration (iiij.
Immunise to Prevent Disease and
Promote Full Growth.
The schedule can,be altered according to the
regime favoured locally* and the immunologicals available.
emphasised.
The importance of full immunisation should be
IV• Reasons for Special Care.
It is recognised that certain factors predispose
to disease in children. Malnutrition is the commonest con
dition underlying illness in India, so most of the reasons
for special care concern children who are "At Risk" from this
disorder. These factors include
Low birth weight, less than 2 Kg, ie. "Prematurity".
Twins.
Poor initial gain, less than 500 G a month in the
first, and less than 250 G a month in the
second trimester of life.
Artificially fed babies from a poor socio-economic
background.
Measles, pertussis or recurrent diarrhoea in the
first 2 years.
Death of one parent or a marriage broken for any
reason.
High birth order, 6th or subsequent child.
Use the dots to make other growth curves on the
flannelgraph showing for example
Illustration (iv).
Risk Factors Resulting in Marasmus.
A premature baby gaining poorly because it is
inadequately fed and ending up with Marasmus«
Illustration (v).
Infection and Malnutrition Result
in Kwashiorkor.
.
A child who gains well on breast milk, but loses
weight after measles, then diarrhoea, and finally gets
Kwashiorkor. Attach the picture of the child with Kwashiorkor
(No.10) near the point where this develops.
Many growth patterns can be illustrated in this
way and teaching given about how to avoid the dangers.
V. Family Planning.
Family health is related to family planning. At
the top of the middle of the Flannelgraph and Weight Card
is a Familogram, a.panel to record the attitude and action
of parents to family planning. Under the Red Triangle and
<
s:
5 •=
the pictures of the father and mother apply the words and
illustrations indicating their progressive response to
advice•
a)e Demonstrate the importance of Family Planning with an
example?
1. Under Reasons for Special Care, place the words
“High Birth Order”•
2. Place the dots showing a good gain for 4 months,
then a poor gain to about 9 months, .Explain
that the mother didn’t have time to.introduce
other foods as she was so busy looking after
other pre-school children.
3* Place the word "Refusing” under the Family Planning
section, indicating the parents were not interested
in any contraception at that stage.
4. The word ’’Whooping Cough” should now be affixed in
about the 9th month column and show how there is
a loss of weight for 2 months. Explain that as
the mother already had 5 children to feed and
care for she had neither time nor money to take
this child for Triple immunisation.
5, The mother is now pregnant again and is more responsive
to Family Planning advice. Place the words
’’Considering” and “Loop” under the word “Refusing"
in the Family Planning section, indicating she is
interested in an I.U.C.D. after delivery.
However, the child is now nearly 1^ years old* place
the picture of the child walking independently
(14) at about the 18 months column. The mother
has delivered again, place the picture of the
mother breast feeding her child (1) in about the
2nd month column.
b). Explain the different Family Planning methods that
are' available, and place the illustrative pictures
on the right hand side of the flannelgraph.
1, Pill - Mother rejecting contraceptive advice (21 A)
Mother considering family planning
(21 B) and
(24
Mother taking oral pills
2, I.U.C.D.
-
3, Condom
- (20).
Loop (19).
Stress the importance of spacing children for
the health of child and mother. All these
methods are reversible and suitable for
spacing. The repeated visits of a young
child to a clinic are excellent opportunities
for advising parents about family planning
when they are most receptive.
4. Sterilisation Operation.
Tubectomy- (22),. and
Vasectomy - (23).
Illustration (V). Family Planning Counselling.
-1^
SPECIAL FEATURES OF THE
i
CHILD, HEALTH, ANTENATAL and
TUBERCULOSIS CARDS
( PA T1ENT - RETA INED)
B. M. LAUGESEN, M.B., Ch.B., F.R.C.S., Dip. Obst.
These cards are kept in the patient’s possession, and brought each time to
out-patient clinics. They are kept in a strong plastic bag to keep them safe from water,
oil, dirt and children. They should last for years.
They are comprehensive health documents. They record weight, immunisations,
clinical symptoms and signs, diagnosis and treatment.
They emphasise family planning and include health education advice.
The record is easily available because it is with the patient. Women often
return to their parents ’ home for delivery. If these cards are widely used, the records
will travel with the patients.
This card can supplement hospital-retained records. They can serve as the
identification for the patient’s unit number in the hospital outpatient department.
In all outlying dispensaries, mobile clinics and home visits these cards serve as
the sole record of the patients. (For serious cases a clinic-retained record in addition
may be used.)
Patient-retained record cards are just as likely to be kept carefully by illiterate
patients as by well-educated patients. But both need a little education as to the value
of the card. In Ferozepore we have already issued 7000 cards. Less than 1% of the
patients forget their cards. In neighbourhood clinics these patients can easily return
home for their cards.
Unless the hospital records system is VERY efficient, more than 1% of the
patients’ records are eventually lost. In many cases, patients spend much time waiting
for their records to be taken out, before seeing the doctor.
These cards were designed by COMMUNITY HEALTH DEPARTMENT,
Frances Newton Hospital,
Ferozepore
Punjab.
KRISHAN SUDAMA PRESS,
Ferozepore Cantt.
Punjab*
Hindi/English/Urdu/Marathi/Gurkhali/Punjabi can be printed.
Cards with plastic envelope are priced @ Rs. 25/- per 100. Freight to be paid by
the consignee.
Orders should be placed with
THE MORLEY CHILD HEALTH CARD
This card was originally designed by Dr. David Morley, at Ilesha, Nigeria, some
10 years ago, and has since been used in many tropical countries. It has been modified
for South India, by Dr. Cutting at Jammalamadugu, Andhra Pradesh. In Ferozepur we
have also modified the card further to suit the needs of a hospital in North India.
THE OUTSIDE OF THE CARD
IDENTIFICATION PANEL provides the staff with enough information to avoid
mix-up of cards in a busy clinic.
BROTHERS AND SISTERS: this section helps staff get to know the rest of the
child’s family. There may be a new-born whom the mother has not brought to clinic.
She can then be persuaded to bring the baby the following week. Three or more dead
babies, or seven or more live children in the family, are reasons for special care. And
family size must be known before family planning advice is given.
NOTES : this space is for the doctor or nurse to note diagnosis, treatment and advice
as required.
IMMUNISATION BOXES are filled with the date of immunisation by the nurse.
The doctor may order the injection by putting a small mark in the appropriate box.
The doctor should ALWAYS see the child before immunisation is given, to see that
he is well enough. Triple Vaccine (DPT) should not be given if the weight is much
below the bottom line, as a worsening of marasmus may follow. Patients with fever
and common cold should not be given D.P-T.
THE INSIDE OF THE CARD
REASONS FOR SPECIAL CARE can be noted. From 5000 children seen in
Ferozepur in 1970, the following are examples of babies needing special care:
breast milk stopped before 3 months
weight not gaining over a 3 month period
malnutrition — when weight is more than 2 KILOGRAMS (4 small squares)
below the bottom line of the road to health
serious diseases of mother or child, such as low intelligence or paralysis, tuber
culosis, congenital defect needing operation, anaemia (under
6 Gms haemoglobin)
mother or father dead, blind or mentally ill
3 or more dead children in the family
7 or more live children in the family
extreme poverty.
2
r
‘ROAD TO HEALTH ’ weight graph - formed by the top and bottom lines of the
weight graph. With a combination of curative and preventive care, and correct feed
ing, most parents can attain this for their children. Parents respond well to the
reminder that brain growth occurs rapidly in the first year, and that malnutrition is
harmful to the future intelligence of their child.
The upper weight line is the 90th all India percentile approximate.
The lower weight line is the 25th all India percentile approximate.
This means that 25% of children’s weights will fall below the bottom line. In
India, most babies stay on the top line for the first four to six months, but then drop
below or near the bottom line, due to failure to add extra food early enough.
The Weight Graph can be completed by turning it on its side, and filling in the
spaces at the bottom of the graph. The first space is for the month of birth. Subse
quent months are recorded until the present date is reached.
Example : a baby born in September, 1970 visits the clinic in February 1971
70
September
October
November
December
71
January
February
The first month of each yearly graph is outlined more heavily than the other
months, and this is always the birth month. The years are written at the side. This
method is much easier to use than the standard weight graphs, where age has to be
calculated. The column for recording today’s weight is quickly found.
The weight is recorded between the lines opposite the current month box. Over
or
two, many children will return for 3 to 10 recordings of weight. The rate of
a year
gain or loss of weight will be as sensitive as a temperature chart to the presence of
acute and chronic illness and to nutrition status.
DIET ADVICE is in picture form. Foods already eaten may be ticked and those to
be added underlined. In this way, illiterate mothers may remember diet advice again
given. Preparation of baby’s first foods (suji, potato, banana) should be taught in detail.
FAMILY PLANNING : If male methods are being discussed, fill up under the picture
of the man’s face ; if female methods, under the picture of the woman s face. Space is
usually also available below, on the graph.
-- --------------
THE FEROZEPUR ANTENATAL CARD
This is simple to use. It is based on the check list principle, and so very little
time is taken in filling in the boxes each time the patient comes. The card was designed
for use in busy mobile clinics, to enable the nurse or midwife to thoroughly check
patients, before referring special cases to the doctor. The card is also used for
Antenatal Outpatients at Ferozepur. The aim is to encourage a high standard of care
in a busy clinic. The card is different from other antenatal cards in a number of
features.
THE OUTSIDE OF THE CARD
DANGER SIGNS are emphasised. The aim is to alert the doctor and the patient to
possible danger to the mother or baby. Patients with a cross in one or more of these
squares require special advice and treatment. The list of danger signs is based on
maternal and perinatal death statistics for Frances Newton Hospital, Ferozpur.
PREVENTION OF TETANUS is emphasised. Dates of tetanus immunisations are
recorded in the boxes provided. These injections should be given at one month
intervals. The ideal is three injections, and minimum is two injections. The first
injection should start with the first visit, with the second given one month later. One
booster is given with the next pregnancy. Tetanus toxoid protects those who will
deliver at home under unhygienic conditions. In Ferozepur this was two thirds of all
antenatal outpatients. It also protects the baby from neonatal tetanus.
HEIGHT is used to select possible disproportion cases for hospital delivery. 20% of
Ferozepur patients were less than 58 inches (147 cm) in height. These patients are
much more likely to have a difficult delivery than taller women, and may need Caesarean
section.
HEALTH EDUCATION : Notes on correct diet are included to prevent anaemia of
mother, and prematurity of baby. Good hygiene and cord care at birth are described to
prevent puerperal sepsis and tetanus.
4
THE INSIDE OF THE CARD
CALCULATION OF THE EXPECTED DATE OF DELIVERY is simple. The
squares are filled with the calendar months following the last menstrual period, until
the square for the ninth is reached. Seven days are added.
Example :
A patient attends clinic on 29 January.
Her last Menstrual period was 1 Assoo
by indigenous calendar. This converted
by tables becomes 16 September.
Expected Date of Delivery :
Sep
Oct
Nov
Dec
Jan
29
Feb
' Mar
Apr
May
June
June
23
L.M.P. 16
Months of gestation
0________________
1________________
2 ________________
3 ________________
_____ 4________________
5________________
6
7
8 _____________
9 ________________
____ (9 months+7 days)
VERTICAL COLUMNS for serial recordings of haemoglobin, blood pressure, weight
for each visit, allow easy comparison.
FAMILY PLANNING is included as a normal part of good comprehensive medical
care. Only when the woman and her family are sure of a safe delivery, and a live baby,
can they start planning their family size. Good medical care makes family planning
acceptance more likely. During the antenatal period the woman is more than usually
interested in family planning. The details of previous children help in advising spacing
or more permanent methods.
Until the next pregnancy the mother uses the same card. It can be used as a
hospital identification card. For the next pregnancy a similar record can be stapled to
the first one.
5
*
THE TUBERCULOSIS (T.B.) CARD
This card was designed in Ferozepur at the request of a general practitioner. He
wanted a card which would help the patient to keep up regular treatment, even if the
patient changed doctor several times duting the course of treatment. . The card - should
help the doctors who treat the patient in the course of 18 months, and should help the
patient to stay on treatment for the full 18 months, for a lasting cure. It is used along
with the Child Health Card or the Antenatal Card, if the T.B. patient belongs to one
of these groups.
THE OUTSIDE OF THE CARD
1.
Previous Treatment is recorded in the special panel. This will help alert the
doctor to possible drug resistance or drug toxicity.
2.
Streptomycin Injection Record. The doctor can see if the patient has received
the streptomycin daily, or twice weekly, as ordered.
3.
Prevention of T.B. in the Family. The Mantoux test is useful for preschool
children who have not received B.C.G. and who aie not malnourished. It is best to list
all the household members at the first visit and then see how many will come for check
up. The Child Health Card should be made out for all preschool children contacts,
because poor weight gain on the weight-for-age graph suggests active tuberculosis.
B.C.G. is given to the children if they are still Mantoux negative after 3 months.
4.
Concerning T.B. This health education section aims to encourage completion
of treatment - the main problem in T.B. control. The patient is encouraged to prevent
further spread of the disease by bringing contacts for medical examination. He is
instructed to burn sputum.
THE INSIDE OF THE CARD
1,
Treatment Record - the card allows for 18 monthly visits until treatment is
finished. The patient can see his own progress through the treatment. The date of the
first visit is filled in under columns day, month and year. Then the calendar mouths
are written in consecutively below this (as for the Baby Card) until the bottom of the
card is reached.
Example : a patient first seen on 16 September, 1970, and attending clinic each month
except December,
Day
Month of Treatment
Month
Year
16
0
Sept
70
1
14
Oct
11
2
Nov
3
Dec
13
4
Jan
71
Vertical Columns allow easy comparison of weight, etc. from month to month.
2.
Miniature X-Rays can be filed in small envelopes and stapled to the T.B. Card in the
Chest X-Ray Column, opposite the correct month.
3.
The columns for the 4 standard drugs allow the doctor to select whatever regime
suits his patient best. The card may serve as a prescription, when it is presented at the
pharmacy. If other drugs are needed, they may be written in the column for symptoms
and effects of treatment.
4.
Number of days drug supply given. Pharmacy staff fill this in, because due to
lack of cash or shortage cf drugs, the patient may not collect the amount of drug
ordered. This record of supply failure will help clinic staff to uneaith the reason at the
next visit. Normally drugs will be packed in 15 or 30 day lots, to last till the next
clinic day.
Printed by Sh. K. C. Sethi at Krishan Sudama Press, Ferozepore Camt. and published by
Frances Newton Hospital, Ferozepore Cantt.
PATIENT*RETAINED HEALTH CARDS IN A 250 BED HOSPITAL
B.M. LAUGESEN, M.B.Ch.B., Dip. Obst., F.R.C.S.
Community Health Department,
. Frances Newton Hospital,
Ferozepore,
Punjab.
Comprehensive health records in the patient’s hand 9 to
Summary
supplement the hospital-retained records, were used for 22,000 patient
visits to our hospital maternity ch Lid health clinics in 1970 - 71.
We have also used the card alone (as the sole record), in mobile clinics
for another 4000 patient visits, with success during 1971.
PATIENT RETAINED RECORDS ARE SELDOM LOST
The card is of bright colour (yellow for under fives, green
for antenatals, pink for T.B. patients, and blue for other),
I*
is is 10 inches (25 cm) long when folded, and is kept in a strong plastic
envelope.
It is issued to the patient, with instructions to bring
it for every visit to the clinic.
Antenatals must also be
instructed to bring their card at the time of adnxssion to hospital,
or there is a danger of the card being forgotten in the panic of rushing
to the hospital when labour begins.
Illiterate people who have little paper in the house, seem to
value these cards more than the educated patients who are often the ones
Patients find that they get seen
who forget to bring their cards.
and treated faster when they have the health card in their hands than
when without it.
Even if patient retained records are occasionally
A quick check
left behind, they are very seldom lost permanently,
of most medical records department files will reveal that after 5 years
at least 2% of records are permanently missing.
When used in conjunction with hospital retained record system,
the patient retained card can act as the identification card for the
hospital number system.
PATIENT RETAINED RECORDS ARE ECONOMICAL
These health cards, with the plastic envelope, cost only
A hospital record on a 7 x 5 inch card with accompanying
25 paisa each.
cross reference file, and number identification cards will cost just as
much, while quarto size folder for outpatients, used in some hospitals
will cost several rupees, thus ’pricing out’ the poor patient.
PATIENT RETAINED RECORDS SAVE TIME
The doctor’s assistants using the health cards, can easily
carry out the health checks and tests before the doctor sees the patient.
The weight graph on the child health card, and the columns on the antenatal
He is then able
card give the doctor most of the information he needs.
to quickly assess the patients and decide that protein supplements are
Such efficiency
needed, or immunisations, or anaemia treatment etc..
and speed are essential if routine health care is to be given to large
numbers of patients.
Unless a comprehensive health document is used
either fewer patients must be seen carefully, or large numbers are
’processed’ for immunisation only.
PATIENT RETAINED HEALTH (LiRDS ENCOURAGE A HIGH STAND-LRD OF CARE
When, children, are seen without a weight graph being made,
In India, marasmus which has
most malnutrition will not be diagnosed.
no special clues to alert the doctor, is so much more common than kwashiorkor
Without diagnosis of malnutrition we are
with its clinical signs.
We also
unlikely to treat other illnesses completely successfully.
miss an important cause of preventable intellectual ’stunting’.
The
Morley type weight graph is easily filled in by the doctor’s assistants,
as it is not necessary to calculate age each time the graph is filled in.
Other types of graphs are complicated to complete, and are likely to be
neSleCted*
COMMUNITY HCAtTH CEtt
>
Page 2
PATIENT RETAINED RECORDS ARE
HIGHLY MOBILE AS THE P1TIENTS
Uyon (1971) found that in Punjab villages, 8C^o of first horns
were born outside the husband’s family hone.
For second deliveries 36%
and for third, 24% migrated, often with young children, to the maternal
grandmother’s hone.
For people■in Government service, this customary 1nt.
tian involves long distances,- and an antenatal patient in Bombay nay
deliver her baby in the Punjab.
Tuberculosis patients migrate to
many different doctors in the course of their long illness, and a patient
To ensure
retained record once again saves the doctor much tine.
that the health card is taken by the patient, the patients and staff must
be educated to value then, and relatives must be warned that in the panic
of rushing a patient to hospital, they must remember to bring the card also.
HEALTH CARDS ARE USEFUL FOR HOME BASED HEALTH CoRE.
The health card forms a natural talking joint and personalised
health teaching aid whenever the auxiliary nurse makes a home visit,
The
child’s name already on the card makes introduction easy when the nurse
calls.
HEALTH CARDS ARE USEFUL IN REsearCH.
. '
These health cards have been followed up to remote villages
on a big scale in Uganda, using students in their vacation, on bicycle.
Moffat (1969)
They can be used to document the age-weight incidence
of disease, investigations of birth interval, response to feeding programme^
Laugesonand protein supplements, using mater cards on the doctor’s desk.
1 971 .
HEALTH CJxRDS CAN BE COMBINED WITH THE NUMBERING SYSTEM OF MEDIC >L RECORDS
If the health card is used in mobile clinics, a separate
block of numbers is allotted, and if the patient is admitted he is given
the sane number on his hospital retained records.
V/e use a red inked
ticketing machine for numbering walking records,
The main aim is
to avoid giving two numbers to any patients - the method of doing this vario'
from hospital to hospital.
PATIENT RETAINED RECORDS ALLOW EASY REFERRAL TO AND FROM THE CENTRAL HOSPIT/J
The health card acts as a well documented note of referral
and later, acts as a discharge summary,
CONCLUSION
Mission hospital can without much difficulty introduce a standard
set of health cards that.will be interchangeable between 300 - 700 hospitals
all over the country.
Later on Government islikely to follow suit, for tho .
is no better system of medical record for health care of the vulnerable
groups than patient retianed health cards.
Unless the patient needs
admission, these cards can confidently be used as the sole record of the
patient.
References
L.
Laugesen B.M. (.1.972)
Report forms for MCH Clinics in preparation.
Moffat (1969)
Young Child Clinics in Rural Uganda from Dept Paediatrics
Makerere, Kampala, Uganda.
Wyo.n J.B. and Gordon J.E.
The Khanna Study, Havard University Press
p15
%
IDENTIFIC...TION OF COUPLES URGENTLY NEEDING, FAMILY
PLANTS ING ADVICE
USING THE CHILI) HEALTH CARD.
(A very preliminary report.)
B.M. Laugeson, F.R.C.S., Dip.'OBST., MBChB.
Community Health Department,
Frances Newton Hospital,
Ferozepore,
Punjab.
Summary
The birth interval can be estimated for one’s own patients
by noting when sibs are born to children attending a MCH Clinic, by
noting whore this event occurs on the Child Health Card.
Dialogue
to encourage spacing is then started with all mothers, so as to reach
them before- 5% have conceived.
1'his achieves maximum economy
The Child Health Card used
of staff and time in a busy clinic.
originates from Morley, and was modified for use in India by Cutting,
nt Jainmalaraadugu (Cutting, 1970)
The spacing idea is widely accepted
Wyon (1971) found that in the Khanna villages during 1956-59,
some 25^ of all wives accepted, and 20^ practised contraception if the
methods were made available.
No figures are available yet for this
area, for the group of mothers motivated enough to seek comprehensive
health care for their babies through MCH clinics.
But our impression
is that the percentage would be higher, especially of course for the
wealthier parents in the cities, where the babies attend for immunisation
rather than for treatment of illness.
Spacing seems more popular
than sterilisation, and can be applied to the parents with only 1 , 2,
or 5 children.
Those parents are afraid of permanent methods
because of their awareness of the current high infant mortality rate..
The inprrtance of identifying the group nost at risk.
In a busy clinic for pro-school children almost every mother
But the numbers attending
is in need of family.planning advice.
these? clinics reached 1000 pre-school children a month in our hospital
last year, and in bigger hospitals, the number reaches hundreds per day.
These clinics degenerate into ’immunisation only’ clinics, unless they
But even if health educators or family planning
are properly staffed.
educators are supplied, there will not be enough staff or funds for most
hospitals, especially voluntary hospitals, which must balance their
So it follows, that a method i^ needed to select
budget each year.
those women who are top priority for spacing advice.
(v/o found
that only 1 mother in 30 gets family planning advice in a busy clinic
where nursing staff strongly believe in family planning, but where no
educator is provided.)
Doterizination of Birth Interval frou the Child Health Card.
The Child Health Card has a space for listing all children
' If a 3 yaar old boy cones to the clinic,
born to the mother so far.
who also has a sister aged 3 months, then the entry on his card will be
thus, if the 3 year old is the first born Name
Ranesh
Baby
BROTHER AND SISTERS
Age
Sex
3
M
F
3 months
this one
card i .ade
SIB BORN
in the month
We now take Ramesh’s card, and enter the words
colimn on the weight graph, corresponding to Baby’s month of birth.
The calendar months along.the bottom of the Morley weight for ago graph,
allow us to find the correct month for Baby’s birth without any numerical
calculation.
The position on the card for Baby’s birth will be in
the third to last column in the third year panel of Ramesh ’s weight for
Page
2.
master record o^hKV^! an°?er Child Health Card’ and us®
as a
’ 7
the third to laat coluHn °f
the third X nanef
is hox r
Sibs are alNady boS
Irom thXX
°f the yOunger
ii we iind that 5^ have given birth by 17 months thpn
4-u bXclcePTlon occured ty e „nth., and „ ehouid o.Lt dialog ““ p»Lg nH £3“°“
/
,
WX-LJ. UtJ
V,
There wiXl
he r«rlation.
Moordlrg to prolonged breast tesdlng
(an increase of interval by 10) months in Wyon's study of Punjab viiiages)
due to visits of mother to her own parents (about 2 months increase after
firstborn in Wyon’s
Wyon
the iirstborn
rne
studyJ, about 5 months increase, when the father's
i—
age was 10 years more.)
its
pre-school clinic clientele,
is,
differences between bottle feeding middle class
feeding village
costs very little to find
And it
it costs
vxrxage mothers.
out.
motners.
And
THE DIALOGUE~FOR~SPACING STAMP
^his can be locally copied and stamped
on all child health
cards.
The exact |
stamP wil1 be fixed after local
research.
The stamp delineates the period of dialogue, likaly conception
and expected births.
Acknowledgement
T'
ds. no^ original, but comes from Dr.
D. Morley, Institute of' Childlealth*4
ThP
T:—30 Guildford St, London. WC1 1EH,
The
finding birth interval
U.K. .
ine use of the child health <card’ for
“
locally
ln
inclinics
by
the Evangelical
fied
supported
Oxfam (UK) '-'"
Cu
bv OxfamTuid
Z
C”?
„4 local
local panchayats
paactayat8 and municipal
Church „ Oeroaw, and
nunlcgarX™eB
committees-.
References
Cutting, W.A.M.
1971 .
Morley, David.
J. Christian Med. Association of India, Vol 46,
No 6, p516-322
1971
Personal communication.
Wyon, J.B. and Gordon J.E.
“
1971.
r"
The Khanna
Study - Population problems
in the rural Punjab, Harvard University Press,
p153ff for factors affecting birth
-i interval.
/?■
REPORT FORMS FOR MATERNITY
CHILD HEALTH CLINICS
/r
COMMUNH Y HEALTH CELL
*7/1. (First Fioor)St. Marks Road
BAIVGALOaE - SGO 001
B.M. LAUGESEN, M.B.Ch.B., F.R.C.S., Dip. OBst.
Registers are not necessary at all in Maternity Child Health
Clinics.
But report
They are untidy, and bulky,to carry.
sheets can be duplicated or printed so that the same information is
The report sheets can be handed in to the
collected each time.
Community Health Office or team leader each night for analysis, or posted
‘, so that the reports can be
Project,
daily to the headquarters of‘ the ~
monthly
totals
the
weekly
or
and
done, without interfering with
studied <
the field workers, as happens with registers.
These report sheet
forms are kept on clip boards.
These reports are useful for hospital out-patients and MCH Clinics,
and for branch dispensaries and mobile clinics.
They are used along
with patient retained cards for under five children, antenatal women,
TB patients and others.
THE CLINIC ATTENDANCE RECORD SHEET.
This form records first visits, re—visits, and age groups: under
fives, fives and over, antenatals, and other adults.
CLINIC:
DATE:
•3ira
FIRST
AGE
0
4
5
■
14
VISITS
Antenatal
24 November, 1971 .
Other
6786
6788
6784
1.
6789
6785
2.
6787
5.
This form shows that on 24 November, 1971, the patients seen for their
first visit at the Zira ^linic were: three under fives, two other children,
and one antenatal patient.
It also shows that over 6700 new patients
have been seen since the clinic, or group of clinics, or the project began.
This MCH Clinic number, for which no hospital patient record is kept, can
be distinguished from the hospital unit number by using red ink, whether
by ticketing machine, or handwritten.
For the first visit, the patient's number can be stamped by
For a revisit, the number is taken
ticketing machine if desired.
from the Health Card in the plastic bag, in the patient’s hand.
This
number is entered by hand on the report sheet in the revisit section.
No record is kept of the names and addresses of the patients
As the clinic is held close to the
coming for the first time.
patients’ homes, these homes may be visited, health cards can be inspected
and the percentage of children possessing health cards can be checked.
Numbers are preferred to names, as they are faster to write,
they occupy less space on papar, and can be easily read by staff using
different languages.
In the case of cash clinics, after allowing for poor patients
seen free, whose numbers are encircled, attendance figures must tally
with cash received.
2.
PREVENTABLE DL3EA3E C.)NTRi)L REPORT SHEET
i.hat percentage of patients are completing the three injections
of tetanus toxoid?
Do we need to order more polio vaccine soon,
if the present rush for vaccine continues?
tfhy is Dr A. not giving
Did Patient 6795 and Patient 6784
Triple Vaccine as often as Dr B?
(who are recorded on the pharmacy form as getting high protein supplement
for malnutritionJ, really get Triple Vaccine yesterday?
If so, we
must see Dr C. and warn him of the danger of causing weight loss when
iriple Vaccine is given to malnourished children.
Of the new antenatal
patients on the attendance record yesterday, did all receive first dose
of Tetanus Toxoid yesterday?
These are some of the questions which this form is designed to
answer.
CLINIC
BCG
'7-ira
....
24 November, 1971.
Po_lio
~r
6784
6784
6788
6295
__ 2__
6788
5
(6394)
6594
This record shows that onei under five child (6784) received
BCG along with first dose of polio, that three doses of BCG were used,
and four doses of polio - at Zira, on 24th November, 1971.
If Polio Vaccine is charged at Rs1.50 per dose, the nurse
should have collected Rs6 at the vaccine table, unless there are
patients too poor to pay, in which case the number can be encircled
to indicate this - eg (6594).
Page
3
THE ANAEMIA CONTROL RECORD SHEET
vJhat percentage of the under fives have severe „
Are more than threeanaemia (under 6 Gms Haemoglobin)?
fourths of first visit under fives getting a Haemoglobin test,
or- is this being neglected?
Is it true that more than half
the antenatals have Hb under 10 Gms?
Were the free iron
folic tablets supplied by the government, properly utilised,
only for those with tested anaemia?
How many cases of antenatal anaemia benefited
were treated with these iron folic tablets?
Does the large
proportion of low Hb readings this week indicate dirty glass
tubes in the Sahli apparatus?
Sitting at base,. 50 miles
away from the Clinic, or standing behind the Haemoglobin technician
during the Clinic, the doctor or team leader can find the answers
to his questions on this record sheet, or at least ask himself
the right questions.
To avoid counting higher Hb results due to treatment
is easy, because revisit numbers are much lower than the first
visit numbers.
THE PH^^ACY RECORD SHEET
Uniform selling prices, standard quantities prepacked
in bottles or little plastic bags, a standard drug list for all
clinics, and a standard prescribing pattern, are features of the
mobile pharmacy.
Also standax'd instx*uctiers to - tne patient
for .each particular drug are given verbally by the assistant
issuing the drugs.
The value of all drugs (and vaccines
from the vaccine record) issued in a particular village during
the year can lie used as proof of proper utilisation of the
panchayat grant in aid, in case of free clinics.
For cash
clinics, the total collected will tally with the receipt issued
by the hospital office, and pasted on the pharmacy sheet.
The total monthly expenditure in all clinics on medicines
can be calculated from these sheets, and this information is used
(in big hospitals the drugs for MCH uilnivo will
for budgeting.
be priced out to the clinics each m>nth by the hospital pharmacist.)
Selling prices are calculated'at cost + 20$ approximately,
Typewritten or printed labels are inserted inside the plastic bags.
This makes sure correct tablets are given.
Page
NJ1LNUTRITI0N RECORD
4
- USING CHILD HEALTH C .RD.
Free clinics tend to attract sick children, but because such
clinics are very popular, they give a much better idea of the community’s
health than ordinary hospital statistics.
The level of nutrition in any village or community can be
assessed, using an Under Fives Card.
The weight of one hundred
consecutive children at their first visit to the clinic is marked on
an Under Fives Health Card.
The resulting graph indie tes the age
distribution of the children attending in .percent, and also the percent
more than four small squares (2Kg) below the bottom line of the graph.
This group has^ serious malnutrition, and the percentage in this group
will vary from village to village, indicating the need, for more diet
education and protein supplements in certain villages.
These weight for age patterns need not be studied all the
time, but should be completed in one month, so that the amount of
If the Health Clinic is having
clothing worn does not change.
good impact on the village there will be few new cases of serious
malnutrition because first foods will be introduced early.
This
community change may take two years.
are not so
useful, as at
p first ■
more than the well babies.
Surveys of revisits
/ very sick tend to revisit the clinic
But this card may be used for a hous. to
house annual check of 100 children under five, if the nurse chooses
the same houses each year.
RECORD 0I; DISEASES
USING CHILD HEALTH CARD
Whooping cough, polio, and other common diseases can be also
noted by the same method as above.
..s the patients are seen by the
doctor, their weights 3 are noted on a child health card.
This helps
the doctor to find out the age and weight groups of those who are
struck down with these diseases, so that iminunisation courses can be
given in good time.
For instance, it may be found that no cases of
polio are found in the over three age group - thus allowing saving of
funds for this expensive vaccine.
(And also in times of shortage of
vaccine supplies, saving of vaccine for the most needy group.)
If
those with one, two or three doses of vaccine previously given, are
noted by cicling the patients number on the master card, one, two or
three times, it can be checked whether three doses of vaccine are sufficient.
The brothers and sisters space on the back of the card can be used for
recording disease striking children 5 years of more.
One master
card is kept for whooping cough, one for polio, and others for other
special interests of the cli ic doctor - tuberculosis, hepatitis, malaria,
etc.
These records allow the doctor to steer his community health work
in the proper direction, and f-ave him being dependent Solely on articles
Page 5
FAMILY PLANNING & HEALTH EDUCATION REPORT
This sheet is carried on a clip board by the health educator, or
if none is available, by the clinic Sister.
It is useful for hospitals,
health centres, mobile dispensaries and for home visits.
It measures
the amount of teaching that accompanies the healing work of the doctors
and nurses.
THE FAI.ILY PLANNING SECTION separates the mothers into ’refusers’, ’triers’,
The ’triers’ have accepted the
and ’users’ of modern contraception.
Over the
idea of family planning enough to have tried a modern method.
years we can watch acceptors and users percentages rise, and percentages in
MCH Clinics should be higher than the target of 25% actual users in the
population, which Government wants,to achieve current targets.
After attending to children’s needs for medicine
How to use this sheet.
or vaccine, the health educator interviews mother.
The emphasis is on
A six months boy, the first boy after four
child health.
Examples
girls, is brought fpr vaccine.
The importance of spacing the next baby
is explained - so that maixmum breast milk, food and attention may be given
to this precious boy baby, for as long as possible.
Later the mother may
decide that one healthy son is enough.
If she accepts nirodh or pills,
At
she is listed by the clinic number on her son’s child health card.
the same time, the family planning section on the child health card is filled
Next time this child comes, we can resume the dialogue, and if this
in.
time she wants tubectomy, she is listed in the box for those wanting help.
Space at the bottom of the sheet can be used to note address for follow up
When she has
later by Government, or by the Educator herself,
tubectomy (and a scar to prove itl), we list her in the ’tubectomy done’ box.
The educator
Each time we list her by the number on her son’s card,
herself carries and issues nirodh and pills, so that the mother is saved
further embarrassment.
THE HEALTH EDUCATION SECTION.
We can try and measure quantity df health
Thus total
education given, even if we cannot measure its quality.
number of people reached can be compared with the total number of attenders
at the clinic.
The number receiving talks on immunisation can be
compared with the number immunised, and the number receiving advice on diet
for baby compared with the number already having malnutrition.
Monthwise fluctuations in quantity of teaching nay vary with
the regional language skill of the different educators, with the attitude of
the Ward or Clinic Sister or doctor, and most importantly, with the extent
to which the health educator is expected to help out with nurse duties
when the clinic gets busy.
All these changes will be faithfully
recorded on this record - it is then for the person in charge to find the
cause, and take action.
How to use the record.
Each time personal advice is given to a mother,
record the number on her child’s health card in the individual column.
Every tine a group (5 or.more) is talked to, the number is written in the
Use a separate sheet for each clinic each month.
group talks column.
In busy clinics a new sheet is needed each clinic day.
The entries are
made in different boxes according to the subjects discussed.
The subjects diet, immunisation, etc., can be replaced by flashcard, flannelgraph etc,
if we wish to study the popularity of different teaching aids.
WHY HAVE A RECORD AT ALL?
If we wish to improve our services next month, we must know how good
1.
they are this month.
The health educator should be given the satisfaction of reaching
2.
measurable self-set goals.
ATTENDANCE RECORD
MOBILE CLINICS
Starting
Number
DATE
CLINIC
666
ii
FIRST VISITS
AGE
0-4
1
0-4
OTHERS
ANTENATAL
5-14
ii
2
I
I
5
— 4
;•
5
I
r
6
’
!
TOTALS
I
I
I •
7
.i
8
9
Total First Visits;
REVISITS
1
2
5
4
5
I
>
6 . j
7
I .
o
9
10
; * 11
' 12 . J
15
1
-
i
!
F -14 .’""J
1
1.5
16
17
i
18
i
i
■
<
19
......
\ 20 .
TOTAL REVISITS
I
1
I
PREVENTABLE BISEA SE CONTROL
MOBILE CLINICS
(Record patient’s number
Name of Clinic .
k_ALTH CLLL
COMMcU..
once for each vaccine.. , st Hoor)St. Marks Hoid
3AMGAi-ORE - 560 001
Opening Number.
...........
Bate
j B P I (Triple)
i 1
1 *
BCG
a
POLIO
2
1
5
i
1
2
3
4
r
5
6
7
i
I
I
8
9
i'
I
10
11
12
‘I
TOl'AL
1E3L
------ TAB ’"AiH/rW
Typhoid.
2
1
k
Ter ;,’nus Toxoidanten /tal
FIRST OR Primary
SMALLPOX
Repeat
1
Repeat
4------. *
i
i
2
i
•
I
5 !•
i
3
3
2
Wallpox
4L
6
7
8
...
o
I
totals
Tetanus Toroid
1
2
i
■ <2.
■
Other
OTHERS,
3
6
1 I
2 i
3
4
5 I
S'
TOTALS
1
-
.I
V
J..
GOVT STOCK
ANAEldlA CONTROL
MOBIL* CLINICS
Yes
NO ;
STARTING NUMBER
DATE
CLINIC
If patient receives two packets of the tablets, write his number twice.
, Other treatment
Iron-folic
ffb not
Hb
Hb
Age group “Hb
y-,
.
__✓
I
under 5 (30) or remarks
recorded
10 Gms +
under 6Gms jS-IOGms
(years)
antenatal (60) j
'
today
----------- 1-----------1 .
0-2
- |
2
-b.....
3
4
5
6
7
8
9
10
3-4
1
2
I
3
4
r
5
6
i
7
8
r
ri
r
i
9
10
ANTE
NATAL
1
2
r
I
r
3
4
5 . •
6
7
8
9
10
5-14
Years
1
2 .
i
*3 .
I
4
5
OTHER
1 I
2
3
4
5
TOTAL
i
_4__
MOBILE PHARMACY FOR MOTHERS AND CHILDREN
Date
Name of Clinic
Number of patients
receiving the drugs
Name of Drug
!
t
Rs • 1P
Selling
Rate
No.
Used
9
0.60
’
Ferrous Sulphate
200 mg. (30)
I
f
I
Folic Acid
5 Kg. (15)
t
1
I
FAC Mixture
100 ml.
Imferon 2 ml.
100 mg. Fe. 1 amp.
!
I
!
I
’ o.?o ’
I
t
1
t
’ 1.75 ’
»
»
»
»
t
t
I
9
!
1
9
9
I
9
Sulphadimidine
0.5 Gm. (15)
spirin 75 nig*
1
9
0.90
Phenobarb
30 mg. (15)
Furoxone Susp.
30 ml.
S t r e p t om a gm a
30 ml*___________
Streptomycin
1 Gm. inj ,______
Sequil
10 ml. amp.
Cough Mixt.
.00 ml._________
I
9
9
9
9
1
“f---
9
9
9
9
9
’
9
’
0.30
9
9
9
’ 3.00 ’
9
V
9
2.50
9
r
I
0.75 ’
9
9
’ 1.00
9
9
9
0.70
.■ i i ■ i‘ ■■■■—i ■ —
9
9
9
9
9
’ 0.70 ’
9
9
I
9
9
9
9
9
' 1.40 '
9
9
9
9
free
9
9
9
9
' 0.75 '
9
9
’ 1.55
9
* 0.75
9
9
9
9
9
9
9
9
9
9
9
9
-
9
9
9
9
o'; 90
9
9
9
9
9
9
_
0.60
9
9
INH 150 mg. and Thia-I
cetazone 75 mg. (30)
Atebrin (Mepacrine)
9
100 mg. Tabs. (15)
Other
■■
i
9
9
9
V
0.60
9
9
■
Kaolin Mixt.
100 ml.
__
Punjab Biscuits
packet of 22
F.L.
(condoms)
Zinc Boric Eye
Drops 5 ml.
Torramycin
Eye Tube 3*5 G.
Ephedrine Nasal
Drops 0.25/5 ml.
Multivitamin
Tablets (15)
INH’100 mg.
Tablets (30)
9
9
9
9
?
0.20
ao)
ASA (Aspirin)
300 mg. (30)
I
0.50
'
' 2.40
'
' 0.30
9
MEDICINE TOTAL CASH
M^OICINE TOTAL GIVEN FBEE.
9
V
9
9
9
9
FAMILY PLANNING & HEALTH EDUCATION REPORT
REPORT made by
$
... .DAY. ..........MONTH,.YEAR...
....Family Planning or Health Educator
.DATE ...
........................................
CLINIC/WARD
-
.............
’■rite unit numbers from health cards
;
in these columnss------ ------------------------T-----------------------------’r
Has tried modern
:method, but not
using it now
Not using any
modern method
and never has
, USING
■ I INDIVIDUALS
Modern Method j
SUBJECT
of Talk
GROUP TALKS
i Vrite no. in
’ each group
^“■?gauo<i
i
...J.
1 . .
. : . DIET
2
j
I
*
; 4
5
a
6
i
7 . .
to
° -?
a
. 1 .Total listeners
. ’ 8 . .
.0^.0
•
’
°
• Itotal .
’
.: 9
. HO
•
. TOTAL
« i . PREGNANT . * . .Taking >No|| Issued -11 . .
Pill
i
’
• i*
•
.
.’-12.
F.P
I
.
|
• <• i- • . . U • •
.14
.
.
4
.
.
Husband had . . 16
Vasectomy
. . 17 . .
.
. ;18 . .
TOTAL .
.
. 19 . •
IKTERESTEP & WANT UELP
.
. '20 . .
.lit No. ' No of sons ! Action taken,,
.
( Wife had
------------.. 21 . .
;
■ Tubectomy
. . 22 . .
. .j. .
r
I
!
.
. 23 • •
.
. 24 • •
.
. 25 • •
I
. ir'TJNISATION
OTHER
: Modern Methods
■ Total
TOTAL
TOTAL
i Couples:
. TOTAL
Depending on the number of patients seen, this report is handed in daily, weekly, or monthly,
but a separate sheet is used for each clinic.
Interested couples Totals
IMMUNIZATION RECORD - (Smallpox, Tetanus, Polio, B.C.G., Triple)
Con
Hospital
Roll
Class Tbacher Kindly Sd.ll in
to fill
sent
Kames and Consents,
NY. Child’s Name Yes/No 1 2__ 3
1.
..
r
_____
g.
4.
5.
School
Address" Class
e. r
Section
Roll Total
7.
8.
9.
Arranged dates
10.
11.
Dates Done
Remarks
12.
13.
14.
15.
■ im.
Batch No. Used
' ILn
Roll
No. Child!s Name
18.
19.
20.
22.
23.
24.
25.,
26.
27.
28.
29.
30.
31.
33,
34.
.2^
36.
37.
38.
39.
40.
41.
. 42^
43.
44.
45.1
46>. I
I
i
i
47.1
48j
49.
50.
51.
52.
ism
'54,
r
55..
56.
57.
58.
59.
60.
Con
Hospital
sent
to Pill
Yes/No. 1 2__3
T
4
INFORMATION SHEET FOR VISITORS
MOBILE CLINICS FOR MOTHERS AND PRE-SCHOOL CHILDREN
A Christian Action Programme for a Needy and Under Privileged Group.
Administered by the Community Health Department, Francos Newton Hospital, FerozePur, Punj ab, In dia.
Motivation: Christian
about the 1 in 4 children dying before the age of
concern about
Christian concern
2 in the villages of the Punjab, (see Wyon, Khanna Study, Harvard 1971)•
Theory on which this project is based: Medical care PLUS nutrition care results
' , The same hypoin much improved acceptance of family planning oy the p<rents.
Hopkins
Johns
team in the Punjab
thesis incidentally has been investigated by the
of
World
and Food and
Health
and has been advocated by the Director Generals
Agriculture Organizations•
<
Sponsors:
Government of India - Some vaccines and iron folic acid tablets;
U.K. charity - ---—---u,
running expenses;.
OXFAM, the u.xv.
CORSO, the New Zealand charity - milk biscuits;
Various Municipal Committees and Panchayats - some medicines;
Evangelical Church in Germany - clinic and staff housing;
Total Value of the Project Over 3 Years - $60,000.
NOTE: This
heuvxxy on the curative services of the
This preventive
programme depends
depends heavily
preventive programme
h^Tital to back it up, and
on
fine
reputation
of 75 years work m this
and on the --field. The importance of malnutrition in causing intellectual defect gives
added urgency to a programme of this kind.
Achieved in 1971: 6 weekly clinics started; minibus obtained; 4 medical papers
published; grants approved; 2 other hospitals persuaded o c oose s
projects; records, cards and proformas designee*
Plnnnod for 1972- 10 more weekly clinics to become operational; team to be.
brought u7t-Hjil strength; buildings to be started as soon ,s finance arrives;
hCh dose tetanus toxoid to be tested at request of government; more student
nurses to be trained in community work; Punjabi doctor ^erested in this work
to be recruited to take charge; other mission ^niteas w.ntin to ca^ther
type of work to be given every assistance and visited it
,
,
10,000 school children or villagers to be protected from tetanus;jet gun main
■' ; 30,000 preschool
children
tenance service to be provided for other hospitals;
prescnoolchildr
in
1972mobile
clinics
and 10,000 ontenatals are expected to visit the
m 197 .
other similar schemes to givejersonaiized^mother^and^
To see
Long Term Aim:
in the North of India, and thus
F mission hospital
1— - child services started in every
field for further
important
give government possible working models in this
action as it sees fit.
■(
appreciate the
Further Information of a more
more technical.nature is available,
comments and suggestions of all our visitors, Please do not fail to ask for
further information and give us your ideas.
’’Better to light one candle than curse the darkness.”
SUGGESTED FURTHER 'READINGS :
ed. King,Nairobi(Oxford University
1. Medic al Care in Developing Countries,
Press. )
Young Child Clinics in Sural Uganda, 1969 from Ankole Preschool
2. Mobile
o ___ ___ ________ _ __________ ...—
Protection Programme, P.O. Box 221, Mbardra, Uganda
Medical Cale"for ’the Underfives, Laugescn, B.M., J. Christ Med. assoc.
3.
!_
5.
______
India,
Jet Inject’ors for Immunization, Laugesen, BxM. , ibid. 1971, 11’ Nlnutrition
4. Child
Weight Card Modified"f~o~r India-Pronote Growth_an^reyent_Maln.lri^2£ ’
W.A.I-i., ibid.H p.'~3i.6-3.22.
lug, W.A.M.
Cutting,
and the Developing World, Bryant,
Health
6. J ________
Pr ess. 5
7
(1969, Cornell University
cell
■' health
(First Fl Qor>St. Marks
^-MGAlohe • 560 QQj
Corn h 10-if-
SiPSClAL FSATUnBS. OF THE
CHILD, HEALTH. ANTENATAL and
TUBERCULOSIS CARDS
(PATIENT^ RETAINED)
B. M. Lauce SEN. M.B., Ch.8., F.R.C^„ Dip. Obst.
These cards ere kept in the patient's ^session, end brought eadb rim to
out-patient clinics. They are kept in a strong pWic bag to keep them safe froni witcr.
oil. dirt ai:d children- They should last for years.
They art comprehensive health documtD^3 o They record weight, immunisations,
clinical svmptoras and signs, diagnosis and treatwent.
They emphasise family planning and include health education advice.
The record is easily available because it is wfth the patient. Women otter
return to their parents' home for delivery. If these cards arc widely used the rec-ads
will travel with the patients.
This card can supplement hospital-retained records. They can serve as the
identification foi the patient’s unit* number in the hospital outpatient department.
In all outlying dispensaries, mobile clinics and boms visits these cards vrve a*
the sole record of the patient*. (For /mious cases a clinic-netainsd record in addition
may be used.)
Patient-retained record cacds are just m likt^y to be kept carefully by illiterate
patients as by welb-tdiKated patients. But both need a little education as to the value
of the card. In Ferozcpore we have already iseued 7COO cards. Lew than 1% of thi
patients forget their cards. In neighbourhood dinice tlrsse patients can easily return
Uorae for their cards.
Unless the bospitd records system m VERY efficient more than 1% of the
patients' records are eventually lost. In mny cases, pirients spend much time wnicing
for their records to be taken out. before seeie^ the doctor.
I
These cards w«re dmlped by COMMUNITY HEALTH DEPARTMENT,
Frances Nrwcoa Hospital,
F^Korepote
Punjab.
Orders should be placed with KRISHAN SUDAMA PRESS,
Fewzep5i4: Caittt.
Punjab*
'j j
Hindi/EngHsh/Urdu/Marathi/GurkhaK/RmjaK can fee pasted.
Cards with plastic envelope are priced <@ Ra, 25/* per 100 Freight to ba paid by
the condones.
THE MORLEY CHILD HEALTH CA&D
This card was originally designed by Dr. David Morley, at Hwha. Nigeria, some
10 years ago, and has since been used in many tropical countries. It has been p-.c.J.<ed
for South India, by Dr. Cutting at Jammnlamadugu, Andhra Pradesh. In Ferowpur
have also roedifieri the card further to:suit the need, of a hospital in North India.
TH£ OUTSIDE OF THE CARD
'
IDENTIFICATION PANEL provides the sial? with enough information to avoid
nu.t-up of cards in a busy clinic.
BROTHERS AND SISTERS: this section helps staff get to know the rest of the
child's family. There may be a new-born whom the mother has; not brought to clinic.
She can then be persuaded to bring the baby ths following week. Three oi more dead
Ivil-ies, ar seven or more live children in the family, are reasons for special care. And
faniuy size mu.ct be known before family planning advice is given,
NOTES - this space is for the doctor or nurse to note diagnosis, treatment
as required.
IMMUNISATION BOXES ate filled with the date of immunisation by -he i urse.
The doctor nay order die mjectiOT ^putting » *wdl • mark in the npvtoprke r-x.
The doctor should ALWAYS 5e8 the child before immunisation i3 given, to see tb’t
n-icn
he is well enough Triple Vaccine (DPT) should not given if the wnpht
below the bottom line, as a wowening of marasmus may follow. Patents With ever
and common cold should not be given D.P-f.
THE IHS1OE Q? THE CARD
REASONS FOR SPECIAL CARE can be noted. From 5000 children seen in
Ferozepur in 1970. the following
twites of babies needing special care:
breast milk stepped before 3 ownths
weight not gaining ever a 3 month period
malnutrition^ when weightismors than 2 KILOGRAMS
* below the bottom line of the road to health
small squares?
paralysis.. tuber
serious diseases of mother or child, such ae low intelHgcncc or
axiom, congenital defect needing operation. anaemia (under
6 Gmn haeaaoglobin)
xriother ur father ckad. .blind or mentally ill
3 or more dead children in the family
7 or mote live:children in the toby
exttaffi* poverty.
2
c
‘ROAD TO HEALTH* weight graph - formed by £h? top and bottom lines of the
weight graph. UZieh a combination of curative and prev'Kitive care, and correct feed
ing, most parent* can atfcaia’ this O
chUdten. P&rc&es respond well to the
reminder that brain growth occurs rapidly in the &rst year, and that malnutrition is
harmful to the fatwa
of theit child.
The upp«r weight line is the 90th all India percentile fipprcximatc.
The lower weight line « the 25th all India percentile apptorimate.
This means that 25% of children’s weights will fall below the bottom line. In
India, most babies stay on the top line for the first four ‘ to six months, but then drop
below or near the bottom line, due to failure to add exfrl food early enough.
The Weight Graph can be completed by turning it on its side, and filling in the
spaces at the bottom of the graph. The first space is for the month of birth. Subse
quent months arc recorded until the present date is reached.
Example : a baby bom in Se?teniberi 1970 visits the clinic in February 19/1
70‘
’ September !
u,..,.
---- -j
October
Nov ember
December
71
Jano&ty
February
The first month of each yearly gtaph is outlined more heavily than the other
months, and this is always the bixth month. The years are written at rl-e side. This
method is much easier to use than the standard weight graphs, where af,<* hat ^o be
calculated. The column for recording ioday ’s weight is quickly found.
The weight is recorded between the lines opposite the current month box. Over
a year or two, many children vzill return for 3 to 10 recordings of weight. I he rate of
gain or loss of weight will be as sensitive as a temperature chart to tnc pre? cncr of
actM&id ctenir: illness and to nutrition status.
DIET ADVICE is in picture farm. Foods already eaten^ay be ticked and those tn
ba added undetlfacd. In this way. illiterate motbOT
remember diet advice apm
gives*, Preparaewn of baby’s fin;t foods (suji. potato, bmana) should be. taught in detail.
FAMILY PLANNING : If Biale tnethocfo art being discwsstd.fill up undei the picture
of the ®au s face; if female methods, under the picture of tbs woman’s face. Space is
usually also available below, on the graph.
5
■»
i
1
THS FEMOZlPUa ANTBRATM CARD
i. 1
•••. :>•
.
.■••.•
Thia w shnple to use. It is bsoi on tlze dUck &rt principCc. and so vers little
time is taken in SUmi ^ in the boKes each thne the pstknt ewes. The card was designed
for use in bury .nodite dhiics, to a ^oablR tl» s&uss §r midwife so thoroughly check
patients, before referring special casts to the doctor. The card is also used for
Antenatal Outpatients at Ferozepur. The sha i® to sneourage t high standard of care
in a busy clinic. The card is dissent fcosn other anhaatal cards in a number of
features.
nt
’
THS OUTSIM
.
•
■
THS
‘
'
.1'
DANGER SIGNS are emphcsi&sd. The aim is to alm the doctor snd the patknt to
possible danger to the mother or Ltbfc ‘PaHxntfi ’Frith a cross in one or more of these
squares require special advice and fcreJafmest. The litt of dagger sigj^ is based on
maternal and perinatal death
for Froncea Newton Hospital, Fesozpur.
PREVENTION OF TETANIJS ia empWsed. Dai ss of tetanus immunisations are
recorded in the boxes provided. Thess injections should be given at one month
intervals. The ideal is three injections, and minimum is two injextions. I he first
injection should st^it with the first visit, with the second given one month later. One
booster is given with the next pregnancy. Tetanus toxoid protects those who will
deliver at home under unhygienic mnditioss, la Ferorepur this was two thuds of all
antenatal outpstkota. It also protects the MW feosa ne^ne^l tetanus.
HEIGHT is wed. to select possib^dismop^on cafes for .hospital delivery. 20% of
Ferozepur patients ware lefts than 58 iachea (147 csx) in height* These patients are
much more likely to have a di&calt delivery thsii miler woow, and may need Caesarean
section.
HEALTH SE^JCATION :
ihd^ded ttfprcvsnt anaemia of
mother? and pramatunty or baby. Good hygiea®'«b $ cok’d cast afc bitb a?e described to
prevent puerperal sepsis and t^amss.
‘
'
*
I
4
..I .
€
TH£ INSiDB OF THi CAW ; ^f7
JitT
’•
'
THE EXPECTED DATE Qf DEUVERY u simpU The
CALCULATION
squares ate filhd
the eaUj^^wsthf
men^ruBl period, until
the square icr the ninth is reidhedi SeFttaiSsjs
«s4de«i>
$fo$tk8 of gestation. ,
\
Example:.
.A patie nt sittesdt clime on 29 Ji-nimy.
Hm lact Menstrt®! period
1 Aa^o
by iodi^eno^i caxudas.. This
. ~»r
by tab&s becomes 16 September*
.....
” 0
K:' ZZZEZZTZZZ
7
-Z2^
. )
»*<,-■»
•-
-4-.^
i •«j '
I
• •*
I
2
ZT3ZZZIZL
_:‘ ?
*
.__
—r-y— ,. ■_____
—• 'HMy ; :
7^2.9 "
, Sspc^ed Date c£ DaU^w: •
VERTICAL COLUMNS icr r.ssis’^et’M/is^tK tsenacgMsui, Wcad puwsare. weight
for each vidt.
CGtaperisouL
, 7 '.■ ’ ’,
FAMILY PLANNING is included ks « normal part of ^xx* cor^i^b^h’t snfl&al
care. Only ^hcu the woman and her fesaSy as« surextf & sifi> ddivesy. and a live Uby.
luste family pUitniag
can they mtt planning thmr family iasa/t -Gocd wdlad
acceptance more Htajy. During the antenataltwrlod ^he woman is jnore than tnadly
interested m favdly plannWjg. pwlefie-ih pf
.chUdsen help in advising spacing
or more pennanent Tnethodo..
Until the ne^ pregnancy the‘ mother uses the same card. It W> IX dmo es «
hospital identification card, ^dr the acst pkgna^‘3 jia^njseerd mi be Stapled to
the fic?& one.
TWO TUBERCULOSIS
,
i ’. c.
CAsm
-•
Ibis card was d^ign«d in FerOzepr^ at the request of a general practitioner. He
wanted « earl whidiwoiddbalptheiNtfieirt to keep*up’regular treatment, even if the
patient changed doctor several toss duxing the course of treatment. The. card should
help the doctors who treat the patient in the course of 18 months, and should help ths
patient to stay on treatment for the full 18 months, for a lasting cure. It is used * along
with the Child Health Card or the Antenatal Card, if the T.& patient belongs to one
- .
c-f tlese groups,
4
. . ,
THE CUTSIDE O<F WE <iAR© - ’ t
Prevlatw Trantmamt is reexmded itftbe apccid panel. This T»ili help alert the
1.
doctor to possible drug resistance or drug toxicity.
2.
Streptwydn lajeetfon ReornL The doctor can see if the patient has received
the streptomycin daily, or twice weekly, as ordered.
Prevention of T.8. m th* FamiSy, The Mantoux test is useful for preschool
3.
children who have not received H.C.Gr^ud who me nor malnourished. It is best to list
all the household members at tf-e first visit and then .see horv many will come for check
for ail preschco! children contacts,
up. The Child Health Card should be
beeves poor weight:gain on the., .weightrfor^ftge ’’graph suggests active tuberedosh.
B.GG. is given to th® children sf they are still Manftryjx negative after 3 months.
i .8. 5 his health aduc&titMi asc^xoa aims to encourage compleridn
4.
of treatment * the main problem in T.B. control. The patient is encouraged to prevent
further spread of the disease by bringing contact fo? medical examination. He is
instructed
bum spurusk'
THS: INSIDE OF
CARO
Trcafcnreftft ^a-coyd — the card adaws for 13 monthly visits until treament is
1/
finished. The petient can see bis own progress through tbe .Treatment. The dace c< the
first visit is filled in under cohint s day, month and year. Then the calendar months
are written in con&snztivdy befcw this (as for the Bnby Cerci) until the bottom ci the
card is readied.
Example : a patwtal first aatn m 36 September, 1970. and attending clinic each n:c<tth
except
Month of Trea^uexit
□ay ■ Moatb
Year
0
16
Sept
70
1
14
Oct
2
U
Nov
3
Dec
4
13
Jan
71
2.
■/urtical Col&epfis alk>w efiiy camparssoii cf wight, etc. from month to month.
Miniature X-Rays can fe filed ir. small envelopes and staple to the T.B. Card i;J th*
Chest X-Ray Colstan. opposite the comet siontK
alkrv? the doctor to select whatever regime
3.
The CGltiasm fc^rthe 4 3tstkUr4
suits his patient heat. The card aay Serve es a prescription, when it is presented a* th*
pharmacy.
other dregs are
ebay ma>' be vrittec in th® columa tor symptoms
and effects of treatmeatf.
4.
Number of
drug supply gfo-an. Pharmacy staff §11 this in. because dj» to
lacx ©f cash or shortage of drugs, the patient may not collect ths amount of drug
ordered. This record of supply failure will help clinic staff to oneaith the reason at th*
next visit. Normally drugs will be packed xsi 15 or 30 day lots, to lest till the next
clinic day.
Prictcif by Sh. K. C. 3®i2ii ti JGeshaa Suctasaa PreoSj Fsrozeporc Cantt. and published by
Frcncci l-iawtoa Hespial, Fwozepore Csatt.
/3-y
h
>1 e VMAJ
V |2
VOtUNTARX
C-14.
HEALTH
ASSOC/AT/ON
Community Centre, Sefderjung
OF /NDM
Development Area,
Phone : 652007, 652008
New
Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
VHAI-249
EXERCISE ON GROWTH CHARTS FOR UNDER'FIVES
And Indigenous Calendar
T3
These records are central to all activities in the Under Fives
Clinic, and are now coming into use in many countries.
S SS
X « ?
Lh s 2
To understand how they are used let us take for our example
Bobbi who was 2 years old when seen in summer of 1976 and
we will complete a chart for her. Her mother says Bobbi was born
‘
in May.
<
g7? 1 . <(U
Turn the chart sheet until the boxes in which we fill in the months
M
'-H O' X;
are down the left hand side . (Fig.l)
1
!
c
o c
e
j
JI
Fill in the month of birth, which in this
case is May, in the first space of each 332
year. You will notice that this first
space is more heavily outlined. Write
'MAY* in each of these.
i b/oy
Then fill in ^he other months, as sh^wnJ'jaTT
.TiK
for 2 years.
------------------------------------------------------------------------
h 4-.-
...W.
Once this calendar is completed, we
never need calculate the age again
X
b
How old was Bobbi in July, 1976?
..............................months
I
1---- *
Turn the chart so that the kilogram weights are down the left hand side.
Now, when the child is weighed each month put a large dot in the month
space. (Fig.2)
Bobbi, Bom May 1974
1974 Weight in kilograms 1975
May 3.0
May
6.5
4.0
7.5
June
June
4.5
8.0
July
July
Aug
5.5
8.5
Aug
Sept ’ 9.0.
Sept. 6.0
9.0
Oct.
6.5
Oct.
Nov
Nov. Did not attend
9.5
Dec. 7.0
Dec.
2.5
1975 Jan
Had whooping cough Jan.76 10.0
Feb n 9r5
Did not attend
March 12 0
Feb. Still away
April 10.5
March 6.0 Measles
April 5.5 To Nutrition Feeding •
Centre with marasmus
“5
23 7- I
4
3
z
W—
1
C
’2
>
> o 6
u
a ■
Ha. 2.
r
1.
What
advantages in the
mother keepin , this record?
2,
X-Vhat are the advantage* of this record
over six pa^es of clinical notes?—
3,
List some of the reasons for Bobbi’s
loss of weight following whooping--—
cough and measles
4.
The child illustrates one of the
problems in timing DPT
irnmunirzorirw*
What iq thisi?
BXERCISE IN USE OF INDIGENOUS CALENDAR
When was the child born?
Mother says Bobbi was horn at amavaiya. This was in the month
of Baisakh after Baisakhi, We look at the indigenous calendar (VtIAl-215)
1974
1975
Balsa kh
mid April to mid May
Amavasya in
Baisakh
22 April
11 May
Baisakhi
13 April
13 April
Which month was Bobbi really bom in ?
1.
Rural mothers often do not know the English calendar. *•*How many health workers would know the village calendar?
2.
Would'it be easier to record on the growth chart all months as indigenous or "desi" months from the beginning, without
translation?
------------------------------ --------------------------------
3.
How would we make up an indigenous calendar?----------Which of these events would be important in your area?
Phases of moon
___________
Desi months
------------------------Local village festivals and markets
Events such as floods, famind, new road
Seasons for planting and harvest,
4.
which languages would be needed and which staff would find
------------------------------- ------------it useful?
Com h < 2- G
Upgrading of Medical Records with Local Resources
4
B. M. Laugesen, FRCS
Frances Newton Hospital, Ferozepore Cantt., Punjab.
Summary :
This paper describes the reasons for, methods, and results of a change
from alphabetical filing to a unit number system for patients’ medical
records in a 210-bed hospital. Without much expenditure, enormous
improvement in public relations and increased utilization of patients’
records for research has resulted.
Costs are compared.
Introduction :
The Frances Newton Hospital in Ferozepore admits 6000 in-patients
and treats 15000 out-patients yearly, and has 210 beds with over 100%
occupancy. The medical records room is 20 feet by 15 feet, is situated in
the out-patient department on the same premises as the rest of the hospital.
In 1969 there were only two part-time records clerks who, though very
quick at sorting through the alphabetical files of previous year, could not
prevent long waits for most patients while the records were found or could
not be found. Some 10% of the records were probably lost permanently
through misfiling or in other ways. Seme patients had two, some three,
additional records made out because the original could not be found. This
caused difficulties for the doctor who now had only half of the record in
his hand for decision making. Some patients got their card in five minutes
but others, after waiting an hour or more, suggested we introduce a number
system.
The advantages of number systems :
After studying both methods with our staff, we can say that numbers
are much faster to use for filing than an alphabetical system. Numbers lead
47/7,
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to fewer filing mistakes and routine file checks for any mistakes can be done
very quickly. Punjabi names do not lend themselves to unambiguous
English spellings and sometimes the name is changed by the patient, or
mis-spelled at time of admission in the middle of the night. Misfiling then
results from the mis-spelling.
Numbers can be clearly stamped by machine.
They are much faster
to write and take up less space than names, especially if the father’s name
has to be also recorded in the register. However, most hospitals do not
get much advantage from numbers because a multiplicity of out-patients
and in-patients’ numbers are re-issued each year or with each admission and
the numbers are not the basis of the filing system.
The Unit Number System
The patient is given a number, He shows this every time he comes
to the hospital, year in and year out. Our ticketing machine actually
stamps this same number four times :
1. On patient ’s identification card (incidentally we use the back of
this card as an immunisation record). As our ticketing machine has six
digits, the present unit numbers will last our hospital for twenty years.
2. On the patient’s medical record. Whether out-patient or in
patient, the patient has only one number which is equally necessary on all
laboratory and other requests, and in all hospital registers; for example,
operations, deliveries, death and birth registers.
3. On the patient’s alphabetical cross index-card. This card contains
enough details to identify the patient and is filed by name and in case the
patient forgets to bring his identification card (5% of the patients). The
patient’s unit number can thus be found.
4. In the out-patient register. All new patients including emer
gency admissions, have to be given unit nmbers through this register.
2
The unit number replaces all other numbers. By emphasizing this
number to the exclusion from the patient’s record of all others, it becomes
possible to insist on its inclusion. It is important to use some sort of unique
number to prevent wrong operations and wrong blood given. We have had
four patients with the name Surjit Kaur on the list for tubectomy on the
same day, from the same ward, but one was for tubectomy only; the others
needed other procedures at the same time.
The patient is identified thus : Kanta Devi, Unit No. 123450, and
this can mean no one else. Newborns are given a number at birth. The
more the number is used, the more useful it becomes.
Terminal Digit filing
This we have used in combination with the unit number system,
although it can serve any type of numbering system. The filing area is
divided into 100 numbered units from 01 through 98, 99, 00. All numbers
ending in “49” go into box 49 so that 3849 is the thirty-eighth card in box
49. This can be speeded up after a few months by subdividing each of the
100 groups into ten, according to the third-to-last digit, so that now 3849
is the third card in subdivision 8 of box 49. This system is quick and
thought to be more accurate than ordinary numerical filing. Any number,
no matter how big or small, can be filed easily by its terminal digits.
For cheap and non-bulky dividers, we cut up old X-ray film and
write numbers on these dividers in white ink. Wood is too thick and metal
sheet is too expensive, for 1000 dividers are needed for division by 3 digits.
Tracer Cards and the despatch register
If patients’ records are disappearing, it is necessary to install devices
to keep track of outgoing patients records. The tracer card is slightly bigger
than the patient’s record and of different color. It records where the
patient s record has gone, with date and unit number. It is inserted to the
files as the patient’s record is taken out. This device is cheap as the tracer
is used over and over again, for different patients. The despatch register
shows which doctor has the patient’s records. It is also a useful guide to
number of patient visits per doctor per month and to the total for all out
patient visits for the month. Only the unit number is used in this register,
not the name. On return, each number checked off means a record safely
returned.
Case summary at time of discharge and disease coding onto cards :
The case summary, in some form, is essential for helping the patient’s
own general practitioner know what has been done This summary is
carboned, one copy remaining in the patient’s record. This copy contains a
square for coding of the diagnosis. Coding is relatively easy for the record
clerk once the doctor has decided the final diagnosis. The Punjab Govern
ment uses the ‘A’ list of 150 causes for disease notificati onby hospitals, as
found in the International classification of Diseases (World Health Organi
zation 1967).
We, therefore, prepared 150 cards, one for each disease. Each day the
uhit numbers discharged are entered on the appropriate disease cards. If
the patient died, the unit number is entered in red. At any time the in
patient disease statistics are up to date, and if monthly statistics are needed,
the cards are ruled off each month. Topical extras, such as tubectomy unit
numbers, can be extracted monthly and entered on this type of card.
We use another set of 150 cards for out-patient diagnosis and enter
new out-patients on these daily. This is more accurate and faster than the
previous method which used to take three months to deal with the statis
tics of the previous twelve months to the annoyance of the government.
Filing of In-patieut records and X-rays
Although ultimately we wish to have the same size quarto record
for out-patients as for in-patients, all in the same folder, this is not yet
economically feasible because of the staff costs involved; also, space is short.
For some hospitals a unified filing system will never be practical even if they
4
could afford it, because their out-patient department is not on the same site
as the rest of the hospital. But this does not prevent the in-patient records
all being filed by the unit number. A terminal digit filing system works
easily. If patient 7849 is admitted, then later his in-patient notes, which
may be needed by the court, will be found in box 49, in numerical order,
except those out-patients not requiring admission will not have any in
patient notes. Their record will be found only in the file. The main file
is kept for 10 to 20 years but the notes are kept for much less time if these
contain only nursing records.
X-rays are also easily filed by unit number, with terminal digit filing.
The filing area is divided into 100 and all the patients’ X-rays are kept
together in the X-ray envelope with unit number on it.
Dates of each
examination can be stamped on the outside then every year all those X-rays
more than five years without further X-ray can be destroyed according to
space requirements. Even if the unit number is lost, the alphabetical cross
reference in medical records department should find it. This system will be
found to be much faster than the common practice of working from the
date of X-ray which is often not accurately known. If some count of
patients X-rayed each year is needed then simply a register of unit numbers
will suffice.
Maximising Human Resources :
With new and better systems in operation, medical records work has
become much more complicated and exacting and staff morale has increased
with the increased skills learned. Accuracy and speed have increased and
few cards are lost. Because so far we have not had time to send anyone
for training in coding, the doctor gives coaching to the records staff in
diagnostic coding and checks the accuracy of the coding done by the clerk.
In a year or two it will be feasible, from the staff point of view, to intro
duce the next upgrading phase if finances allow. Meantime, we have the
satisfaction of having introduced major improvements with minimum
5
financial out-lay, and the medical records staff has the satisfaction of doing
exacting and interesting work.
This staff is now one arts graduate and three matriculates of which
two are females. Salaries range from Rs. 90 - 150 per month.
A comparison of costs
From 2 half-time workers, staff increased to 4 full-timers. Thus per
patient seen, medical record staff salary increased from 17 paisa in 1969 to
70 paisa in 1970. However, the previous staffing was insufficient and ex
pensive in lost goodwill from the public. Stationery and printing costs
have also increased by about 20 paisa per patient. Also, there were cartain
initial costs in filing boxes and ticketing machine, about Rs. 400 or 2 paisa
per patient if spread over the first year. The cost of improved service to
the hospital is 80 paisa more per patient. This amount has been recovered
without difficulty from the patients in the form of consultation fees which
formerly were waived on certain days of the week. Attendance of out
patients has not lessened.
Use of Patients records for study purposes
Now about 100 records are taken out (up to 700 maximum) for study
each month, wheieas formerly 10 would have been the maximum one could
hope to extract. One can select by age groups, diseases, operations, deaths,
deliveries, or by doctor, or by date seen, or time of the year admitted. A
comprehensive study of deliveries using computer is now possible and
studies of anemia and malnutrition have been completed.
A Date-of-Birth numbering system for under-fives:
Morley (1966) from Nigeria, suggested using a patient number incor
porating the date of birth. Then Dr. Cutting of C.S.I. Campbell Hospital,
Jammalamadugu successfully introduced such a system for under three year
olds in rural clinics in Andhra. A child born cn 14 February 1969 will be
given the number 14-02-69-03, and “03” means he was the third such child
6
having that birthday to register. The register is divided into 365 and the
top and the bottom of each page can be used for different years but same
day and month. Once ruled up, such a set of registers can be used for
several clinics, so a child may attend different clinics and some record is
available if he should lose his under-fives weight card (normally carried by
the mother). If the date of birth is not accurately known it can be
“guestimated” fairly well by using a conversion table from indigenous to
English calendar with festival dates marked on. As Dr. Cutting has pointed
out, filing of information by date of birth makes cohort analysis of records
very easy. We have not used this system in our central hospital but
it is certainly useful for a rural branch hospital or mobile clinic for the small
children.
Walking Record Systems
Most medical practitioners and most civil hospitals still rely heavily
on walking record systems - a prescription - summary sheet or record card
kept by the patient. It is probably true that most X-rays are filed (and
framed) in the same way. These systems are cheap but the important thing
is that they are 95% effective, being quickly retrievable even if in poor
condition, without delay, 19 times out of 20. The same applies to underfives Morley weight cards. Walking record systems may be more effective
than other systems in rural or mobile clinics where trained records staff are
not available. It follows that unless Medical Records departments can give
a service far better than the fairly effective cheap alternatives available,
then they cannot justify the expenditure required to run them.
The first criterion of a good doctor is availability, and the same
applies to the patient’s medical record.
Acknowledgment is gratefully given to Medical Records personnel,
Christian Medical College, Ludhiana, who provided many good ideas, and
to our own hospital staff, many of whom worked very hard to get the new
system introduced on January 1, 1970.
References:
World Health Organization (1967) International Classification of
Diseases 1965 revision; Vol. 1, p. 435, Geneva, World Health Organization.
Morley (1966) “Medical Care in Developing Countries” ed. King;
Nairobi Oxford University Press.
Printed by Shri K. C. Sethi at Krishan Sudama Press, Ferozepore Cantt.
8
CorvA
3‘
VOLUNTARY HEALTH ASSOCIATION OF INDIA
VHA>‘
vcX \
tv
°l
C-14,
Community Centre,
Safdarjung
Phone : 652007, 652008
Development Area,
New Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
HR-24
A RECORD SYSTEM FOR
COMMUNITY HEALTH SERVICES
USING VILLAGE HEALTH WORKERS
- Murray Laugesen
PRINCIPLES_FOR_COWNITY__RECORD SYSTEM^
• ^e set the health priorities first before we design the records .
2. Standard records. Most health priorities are predictable e.g. Tuberculo
sis is a priority problem everywhere. So is malnutrition. The records
therefore be standardised for comparison with other projects.
3. Records must be logical and simple. Ask why each question is asked. Every
question costs paper and time and salary. Do yearly check and remove any
records that have been kept but not analysed or used for decision making
in the past year.’ Top level permission should be needed before starting
a new register or printing a new form. Keep records simple.
A- The record must be present wherever health care is given. The records must
be easily available, where and when needed. Therefore, there should be
only one record and one number for each patient (unit record, unit number
system). This means that once we run several clinics in the same area,
we need records that are mobile with the patient (home based). This holds
good for OPD and community clinics and home visits with the home based
health record cards. But inpatient notes are kept by the hospital and a
summary written on the patient’s card to take home. If the out-patient
can use home based records also as their sole record it will greatly sim
plify integration of the hospital and the community clinics.
Records must be of low cost. Standardised records make bulk printing
possible. Thus bulk printing by VHAI or the Voluntary Health Association
may be preferable.
5. Let the people help keep their own records,
ask the people to keep their
own personal health records. We ask village women health workers to keep
their own workers notebook. Thus the village people learn how to care for
their own health. Therefore, the records have to be kept at least partly
in the regional language. Costs are also kept low, if we can use village
people to >slp with some of the record keeping.
A LOW COST EFFECTIVE RECORDS SYSTEM
Best results come when we adopt the entire system.
1 • In the hands of the people - home based health records.
HR-1 (child) HR-2 (mother) HR-3 (TB) HR-A general-adult and school child)
HR-3 (leprosy) HR-6 (explanatory booklet) HR-7 (eye). These all contain
both English and the regional language.
2. For the village health worker - HR-23 (Local Health Workers Notebook)
This is filled in regional language,
each panchayat.
She used a separate note book for
3 - For the Mobile Health Team
a.For the Health Supervisor (health visitor, public health nurse or expe
rienced registered nurse.) She keeps her own HR-23 notebook but instead
of individual patients names, she writes names of villages.
2
Reasons for special care - Tuberculosis
Patient's name
Remarks
Village Sarinwala.
6 TB (regd)
J anuary
.
5
February
6 (attended)
This Indicates that
Health Worker,s P’rfcnnance on
TB is satisfactory, This is verified by spot
check to
to one of these ra~
verified
by
spot
check
tients.
_
- supervisor
8 such workers each week doing' a
supervise B
may
half day clinic*with the health team.
The VHW of that place attends.
b) Lor team leader (Dr or Supervisor)
Lousewiso maps of all villages served,
board and put inside plastic.
These are mounted on cloth or card
c) For the person registering the patients.
for all
gxclostylea worksheets for
by
^uiosuyiea
clinics
all clinic5
tabulated. (Examples
&i¥Vxli XIl
in the booklet - Patient Retained Health
-re given
Records - HR-6, published
by VHAl)
These record: patients attendance
vaccine given, drugs sold,. Separate sheets
sheets are made out for every clinic
in eveiy village.
d) for the team's Cashier
nerloHr
worker's
busy clinic^
and cost about Rs 2/the
?aper.anisalary. Cinema type tickets ■______
are prenumberedj and
say numbers Z>000 to 5099
printed
X phe “orninS for
....
,
' Of red tickets
printed ao Receipts for Rs 0.50. /'At
* the
‘
end of the day he hands in money
against every ticket not returned We
for say Rs 0.25, 0.50 and Rs 2/- ' jJxUSe different coloured tickets printed
and then round off all charges in the clinic
to the nearest 0.25 (upwards),
.
H81,
as t,he bus conductors record the number of tickets sold (on certain sections
of the journey, the fee income for
each village can be entered
on pre tabulated cyclostyled sheets.
4. For the base office
is a
" tSXo COnPXlsul’ts oTaulh:^
b. A bound master Leprosy register with a i page
for are
eachc village by number,
egularJty of treatment is recorded. Its
pages
enlarged permanent
SS
^
23
“
f
°
r
vSi7
the
i
“
patient allow us to record 2x12 months of treatment. » 1 lines per
c. A similar Tuberculosis register
d- Village and house to house survey sheets completed
e. Attendance Registers for mobile team and base st
and analysed (HR-22)
to sign daily.
f.• Financial________
Reports, Salary Registers,
. separate ledgers etc, as for any
cost and income centre in a ‘hospital.
v
(Refer Accounting Guide
for Voluntary Hospitals by VHAl 1974)
g« Registers for free jsupplies received and issued.
and copis of reports sent
to the donors or Government.
Inventory of Equipment
checked regularly.
>
3
i. Log Book of the Project.
more safely in future.
This will help others to sail the same s;-s
j. Personnel tiles. One for each worker, (appointment letters etc).
k. Annual reports. Quarterly end monthly reports.
Corr03uondenee.
!• -.7....- , with donors, advisors, villages, suppliers and the incharge , of institutions and Managing Committees.
Other record systems that have been tried.
Family folders: One worker is needed to pull these folder before each patient is seen, The folder is not usually present during home visits, nor
during
patient’s visits to
4-^ base’hospital.t storage costs extra.
4-^ the
Small identification cards and tickets.
These are small and easily lost.
Outpatient cards in boxes taken out in the hospital vehicle.
These records are not available forborne visits, They get misplaced. They
require staff to pull them, They do not inform the patient as he cannot study
what is said about him. They usually record illness care and not health care.
Further copies of this paper and all recommended health records are available
from.
Voluntary Health Association of India
C-14 Community Centre
Safdarjung Development Area
New Delhi 110 016
India
October, 1977
Position: 2627 (2 views)