Table 7.

Clinical data elements for a data set of CMRS

Section name	Data elements
Medical History	Mandatory Weight loss or no weight gain in the last three months- History of a specific disease in the child (mentioning the type of disease)
	Optional History of burns(Yes/No)/ Burn site/date- History of surgery- History of individual allergies- Drug sensitivity/drug name- Food allergy/food name- History of a specific disease in family and close relatives (mentioning the type of disease)
Anthropometric indicators	Mandatory weight at admission - Height at admission –Age- BMI for age
	Optional Birth weight- Birth height- Head circumference- Birth Z score- Z score weight for height- Z score height for age- Z score Weight for age- MUAC
Clinical examination	Mandatory Digestion and liver: Diarrhea- Vomiting skin and hair: Edema- Dermatitis
	Optional Digestion and liver: bloody diarrhea- nausea- Bloody vomiting- Bloody stools- Cough- Chronic cough- Constipation- Swallowing disorder- Anorexia- Fever- Chronic abdominal pain- Acute abdominal pain- Flatulence- Abdominal tenderness- Abdominal mass- hypoglycemia- Hypothermia Kidney and urinary tract: Kidney failure- Dehydration Brain and Nervous: Mental retardation- Hyperactive- Decreased consciousness- Convulsions- Tremor- Headache- Ataxia Skin and hair: Eczema- Paleness- Seborrhea around the lips and nose- Cellulite- Dermatitis caused by photosensitivity- Acrodermatitis- Follicular hyperkeratosis (such as sandpaper)- Skin without pigment- Purpura- Scrotal and vaginal dermatitis- Perinatal abscess- Hair loss- Coin hair loss- Alopecia- Unpigmented and dull hair that is easily pulled out- Hirsuitism- Recent hair color change- Dandruff- skin itching- skin dryness- Yellowing of the skin- Urticaria- Hyperhidrosis Subcutaneous tissue: Tissue Reduction Sight test and eye examination: Adaptation to darkness- Sensitivity to light- Color differentiation- Bitot spots, xerophthalmia, keratomalacia- Conjunctival pallor Face, mouth and neck: Corner stomatitis- Cheilosis- Bleeding from the gums- Papules atrophy- Soft language- Glossitis- Cavities(Tooth Decay)- Dysgeusia(Decreased taste sensitivity)- Goiter- Hypogonadism- Rosary bead- Bleeding under the skin- Skull bulge- Wide Fontanelle- Cranial softness- Painful bones to the touch- Painful head vertex in touch- Spoon nails (koilonychia)- Sensorimotor neuropathy- Ocular muscle paralysis- Tetany Pulmonary: Atelectasis- Pneumothorax- Emphysema- Pleural effusion- Pulmonary abscess- Bronchopulmonary- Dysplasia Cardiovascular: Heart failure- Dilated- Cardiomyopathy- Atrial arrhythmia- Ventricular arrhythmia- Endocarditis- Tetralogy of Fallot- Dextrocardia Musculoskeletal: Joint pain- Muscle pain- Dry joint- Arthritis- Movement restrictions Psychiatry: Schizophrenia- Anxiety- Depression Duration of symptoms
Nutritional data	Mandatory Type of feeding (Breast milk/formula or both / family food / complementary nutrition)- Nutrition Supplements and vitamins in use- Daily consumption of vegetables and fruits- Drinks frequency and amount
	Optional Age to start complementary feeding of infant-Feeding method (Oral / NPO / TPN / Intestinal feeding by gavage or EN / Part of feeding intravenously or PPN / Other)- Food habits- Junk Food- Water source and its health status (protected or not)
Physical activity and sleep	Mandatory Sleep quality (good/average / …)- Physical activity and its duration in the day- Average walking per day (for example, from school to home or Conversely)- Average daily time spent watching TV- Average daily time spent playing mobile phone games and using computer
	Optional Duration of sleep- Delay in falling asleep and its rate- Waking up in the middle of the night (yes/no)/ its rate
Lab Tests	Mandatory Hematology: Hb- ESR Biochemistry: Total Protein- Albumin Serum- Pre Albumin- retinol-binding protein- Globulin- TG- Cholesterol- HDL- LDL- AlP- ALT(SGPT)- AST(SGOT)- FBS/ Glucose- Hb (Hemoglobin) A1C- Serum Iron- Ferritin- K- Mg- Na- Folic acid- BUN- Creatinine- Uric Acid- Vit.B12- Vit.B1- Vit.B2- Vit. A- Vit.D- Zn- Selenium- Iodine- Calcium- Phosphate- Urin: Urine- analysis/ UC Stool: Stool analysis/ SC hormone levels: TSH Test time
	Optional Hematology: WBC- RBC- HCT- MCV- MCH- MCHC- Platelet- MPV- PMN- Lymph- Mono- EOS- Retic count Biochemistry: VLDL- T.Bil- D.Bil -PT/ INR- PTT Sweat: Sweat Chloride test(CI) hormone levels: T3- T4
Other Paraclinical Tests	Mandatory Medical Imaging: Type of medical imaging (MRI, CT scan, ultrasound, …)- Anatomical location- Date of medical imaging- Result
	Optional Pathology: Biopsy site- Date of receiving the specimen – Result- Date of receipt of the result
Diagnosis	Mandatory Undernutrition- Wasted- Severely Wasted- Stunted- Severely Stunted- Underweight- Severely Underweight- Mineral deficiency- Overweight- obesity
	Optional Refeeding syndrome- Kwashiorkor- Nutritional marasmus- Diagnosis code in ICD-10
complications	Mandatory Complication(yes / no)- Complication name
	Optional Date of onset of Complication
Care Procedures	Mandatory Nutritional interventions: Recommended dietary supplement (drug supplement / natural supplement)- Vitamin intake (yes/no)/Vitamin type- Micronutrients (yes / no)/Type of micronutrients Pharmacotherapy: Need to get medication (yes/no)- medicine name- Dose Surgery: Surgery (yes/no)- Name of surgery- Result
	Optional Nutritional interventions: Other recommendations Pharmacotherapy: Date of Start taking- End of use Surgery: Date of surgery- Anesthesia medication received Action code in ICD-9-CM
life status and follow-up	Mandatory Status (improvement / no improvement/referral / non-response / death /other)- Need to get food parcels -Next follow-up date
	Optional Death (intermediate cause / underlying cause/date/relationship between death and malnutrition / …) Source or method of follow-up (telephone contact with family/patient file / HIS /SIB system / other)

Note

MUAC: (Mid-Upper Arm Circumference)

LOS: (length of stay)

SIB : Health Ministry’s Comprehensive Network is entitled SIB (an abbreviation for the Persian equivalent of ‘integrated health system’), which is the EHR system