Date of Admission in programme Date of Discharge from programme
SAM No..MP- - -..................................................... NRC SAM CHART ___/___/___ ___/___/___
Register No……………………………………………………. District................................... Major Problem: Time of Admission………………. Output Indicator :-
Sheet No………………………….……………………………………. Block...................................... Type of Admission:- 1. Cured □
Patient's Name…………………………………………………..NRC Name……………............. Complications Y / N 1. New Adm □ 2. Death □
Parents Name……………………………………………………………..
Age of the Child (m) 2. Relapse □ 3. Non Respondent □
If Yes:
Address…………………………………………………………………. (dd / mm / yy) 3. Readm <2months □ 4. Medical Transfer □
Caste........................................................................................
Birth Date _____/_____/______ Sex……………………………. 4. Transfer from NRC □ 5. Defaulter /LAMA □
1) Referred by: Own □ AWW □ ASHA □ NRC □ 2). Appetite test : Pass / Fail 3). Breastfeeding Y / N 4). Complementary food Y / N ………….…Type……..……
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Anthropometry
Date
Height/Length (cm)
Weight (Kg)
W/L Z score
MUAC (mm)
Oedema (0 to +++)
Target weight:- 15% weight gain from weight on admission (free of oedema*)
Weight Chart (Weight in grams)
.........kg ...
......g
* For oedematous child
admission weight will be
the weight taken on the
day the child has no
oedema
6 7 8 9 10 11 12 13 14 15
Date
Phase
F75/F100/F100D
No. of feeds/day
ml/feeds
Total ml/day
Type of food (SF)
No. of feeds / Day
Gram / feed
Total Grams / Day
Diet
Appetite test (P / F)
Feeds in hours
A=Absent 1
V=vomiting
R=refused 2
NGT=Naso gastric tube
IV=IV infusion 3
Volume taken 5
6
100% (Full meal)
7
75% (3/4th meal)
8
50% (1/2 meal)
9
25% (1/4th meal)
10
....ml=extra
Other Food taken / day
TO BE FILLED UP BY THE DOCTOR / PARAMEDICAL STAFF AS APPLICABLE
4 5 6 7 8 9 10 11 12 13 14 15
L 2 3
Alert / Lethargic
Sto ols IIII - No.
Vomiting IIII - No.
Dehydrated - Y/N
Cough - Y/N
Surveillance
Septic shock - Y/N
Resp/min >40/mn >50/mn
Pale conjunctiva - Y/N
Temp.AM .Ax/Rec
Temp PM Ax/Rec
Liver size cm
TO BE FILLED UP BY THE DOCTOR / PARAMEDICAL STAFF AS APPLICABLE
7 8 9 10 11 12 13 14 15
DATE
Vit A……….iu
Folic Acid mg
Routine treatment
Amoxicillin /
Antibiotic
Anti-malaria
Deworming II
Zinc
Magsulf
Potchlor
Iron Syrup
Multivitamin
TO BE FILLED UP BY THE DOCTOR / PARAMEDICAL STAFF AS APPLICABLE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Specific Treatment
Resomal ml
IV Inf/Transf
NGT
TO BE FILLED UP BY THE DOCTOR / PARAMEDICAL STAFF AS APPLICABLE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Hb
Malaria test
Labo
TB Test
OBSERVATION:
OBSERVATIONS:
Details of Follow Up after Discharge
No. of Follow up
1 2 3 4
Date
Weight
MUAC
Length / W/L Z
Score
Remark
COUNSELLING SESSIONS National Immunization Schedule
Person who took IEC Material & Duration of
Days Topic Date
session Method used session
Age
Vaccine
General hygine and sanitation (personal &
Day 1
environmental) Birth 6 weeks 10 weeks 14 weeks 9-12 months
Immunization (ANC & children using MCP
Day 2
Card) Primary vaccination
Day 3 Nutritional care for young children BCG X
Day 4 Causes of malnutrition in children Oral polio X X X X
Day 5 Care of sick children DPT X X X
Day 6 Appropriate way of cooking food Hepatitis B* X X X X
How to make nutritious food with available
Day 7 Measles X
resources at home
Day 8 Breast feeding practices Booster Doses
Day 9 Complementary feeding practices DPT + Oral polio 16 to 24 months
Providing sensory stimulation & emotional
Day 10 DT 5 years
support through play activities
Tetanus toxoid
Day 11 Care of mother & family planning At 10 years and again at 16 years
(TT)
Importance of weighing the child and growth
Day 12 Vitamin A 9, 18, 24, 30 and 36 months
monitoring
Follow up & care at home after discharge
Day 13
from NRC
Day 14 Followup and recap of all the sessions
