Table 3. Documentation in the case notes (irrespective of result) of clinical features required to make inpatient assessments according to WHO guidelines for care.
| All admissions (n = 509) | Number with any recorda | Interquartile range (%) |
|---|---|---|
| Duration of illness | 462 (91) | 89–98 |
| Age in years or months | 448 (88) | 91–100 |
| Fever history | 436 (86) | 76–90 |
| Temperature | 413 (81) | 68–92 |
| Pallor | 291 (58) | 31–81 |
| Cough or difficult breathing | 258 (51) | 51–70 |
| History of vomiting | 253 (50) | 44–54 |
| Weight recorded | 250 (49) | 12–51 |
| Diarrhoea | 173 (34) | 35–46 |
| Hydration statusb | 90 (18) | 13–30 |
| Convulsion in this illness | 63 (12) | 5–17 |
| Respiratory rate | 54 (11) | 1–15 |
| Mental statec | 47 (9) | 0–11 |
| Able to drink | 35 (7) | 0–13 |
| Oedema | 29 (6) | 3–11 |
| Neck stiffness | 26 (5) | 2–1 |
| Heart rate | 19 (4) | 0–2 |
| Cyanosis | 15 (3) | 0–5 |
| Any diagnosis of malariad (n = 299) | ||
| Malaria slide result | 175 (58) | 21–88 |
| Pallor | 202 (68) | 54–93 |
| Difficulty in breathing | 45 (15) | 4–37 |
| Mental state | 27 (9) | 0–17 |
| Haemoglobin result | 166 (56) | 17–67 |
| Any diagnosis of pneumonia (n = 191) | ||
| Able to drink | 14 (7) | 0–11 |
| Chest in-drawing | 62 (32) | 16–45 |
| Respiratory rate | 29 (15) | 5–25 |
| Cyanosis | 11 (6) | 0–11 |
| Any diagnosis of gastroenteritis (n = 103) | ||
| Fever history or temperature recorded | 96 (93) | 9–100 |
| Hyrdration statusa | 56 (54) | 26–85 |
| Mental state | 8 (8) | 0–11 |
a Percentage of total indicated in parentheses. b Any statement on the hydration status or presence/absence of sunken eyes or delayed skin pinch. c Any note on alertness, lethargy, Blantyre or alert-verbal response-pain response-unconscious (AVPU) scores. d Diagnoses include any admission or discharge diagnosis; cases may appear in multiple categories.