Art3_Fig.1_Medical Record for Emergency and Disaster (MRED) Form.xlsx

	A	B	C	D	E	F	G	H
1	Team Name:		Site: Date: / / (d/m/y)
2	Medical Record for Emergency and Disaster			WHO-MDS Ver1.0 (check all that apply)
3	ID:	Name:		Sex & Age	Age			☐ <1 ☐ 1-4 ☐ 5-17 ☐ 18-64 ☐ >65
4	Age:	Sex ☐ Male ☐ Female (Non-pregnant / Pregnant)			Sex	1	☐	Male
5	Age:	Weight: Kg, Height: cm				2	☐	Female (not pregnant)
6	Address:					3	☐	Female (pregnant)
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8	Triage category	☐ Red ☐ Yellow ☐ Green ☐ Black/Blue/Gray
9	Hazards (if any)	☐ Chemical ☐ Biological ☐ Radiological ☐ Nuclear ☐ Explosion
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11	Chief complaints			Health Events	Trauma	4	☐	Major head / spine injury
12						5	☐	Major torso injury
13		Trauma ☐ No ☐ Yes				6	☐	Major extremity injury
14		(☐Blunt ☐ Penetrating ☐ Fall ☐ Traffic accident ☐ Burn ☐ Others)				7	☐	Moderate injury
15	Vital signs	BT: ℃, RR: /min, O2 sat: % ( ), GCS : E V M				8	☐	Minor injury
16	Vital signs	BP : mmHg, PR: /min, Pain score: /10			Infection	9	☐	Acute respiratory infection
17	Past history & Comorbidity	☐ DM ☐ HTn ☐ Asthma ☐ Breast feeding				10	☐	Acute watery diarrhea
18	Past history & Comorbidity	☐ Other ( )				11	☐	Acute bloody diarrhea
19	Medication	☐ No ☐ Yes ( )				12	☐	Acute jaundice syndrome
20	Vaccination	☐ Unknown ☐ Tetanus ☐ Measles ☐ Mumps ☐ Rubella ☐ Rabies				13	☐	Suspected Measles
21	Allergy	☐ Unknown ☐ Drug ☐ Food ☐ Others ( )				14	☐	Suspected Meningitis
22	Physical exam.					15	☐	Suspected Tetanus
23						16	☐	Acute flaccid paralysis
24						17	☐	Acute haemorrhagic fever
25						18	☐	Fever of unknown origin
26					Additional	19	☐
27						20	☐
28						21	☐
29						22	☐
30					Emerg	23	☐	Surgical emergency (Non-trauma)
31					Emerg	24	☐	Medical emergency (Non-infectious)
32					Others key diseases	25	☐	Skin disease
33						26	☐	Acute mental health problem
34						27	☐	Obstetric complications
35						28	☐	Severe Acute Malnutrition (SAM) *
36	Diagnosis					29	☐	Other diagnosis, not specified above
37	Diagnosis			Procedure & Outcome	Procedure	30	☐	Major procedure (excluding MDS32)
38	Investigations					31	☐	Limb amputation excluding digits*
39						32	☐	Minor surgical procedure
40						33	☐	Normal Vaginal Delivery (NVD)
41						34	☐	Caesarean section
42	Management					35	☐	Obstetrics others
43					Outcome	36	☐	Discharge without medical follow up
44						37	☐	Discharge with medical follow up
45						38	☐	Discharge againt medical advice
46	Procedure					39	☐	Referral
47						40	☐	Admission
48						41	☐	Dead on arrival
49	Follow up	☐ No ☐ Yes (specify: dd/mm/yy: / / )				42	☐	Death within facility *
50	Outcome	☐ Discharge home/shelter --> go to 36, 37				43	☐	Require long term rehabilitation *
51		☐ Discharge against medical advice --> go to 38		Context	Relation	44	☐	Directly related to event
52		☐ Referral --> go to 39 ☐ Admission --> go to 40				45	☐	Indirectly related to event
53		☐ Dead on arrival --> go to 41 ☐ Death within facility --> go to 42				46	☐	Not related to event
54		☐ Require long term rehabilitation --> go to 43			Protection	47	☐	Vulnerable child*
55	Context	Event relation: ☐ Direct ☐ Indirect ☐ Not related (go to 44, 45, 46)				48	☐	Vulnerable adult*
56		Vulnerability: ☐ No ☐ Yes --> go to 47, 48				49	☐	Sex Gener Based Violence (SGBV)
57		Violence: ☐ No ☐ Yes --> go to 49, 50				50	☐	Violence (non-SGBV)*
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59	Signature			Record person				Comment
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