IRON SUCROSE CASE SHEET MODEL-CONTENTS

Name of the PHC / GH: HUD Name:
Name
Age
Husband / Father name
Mobile Number
Full Address
District
Mobile Number of the VHN
HSC
PHC
Date of LMP
Date of Albendazole tablet given
First estimation of Blood Haemoglobin at 14-16 weeks of gestation
Date of first Hb. Estimation
Hb in gms%
If Hb below 7 gm%, write
name of CEmONC Centre
to which referred
If Hb between 7.1 to 10.9 gm.
Date of start of Therapeutic
dose of Tab. IFA
If Hb. above 11 gm, Date of
start of Prophylactic dose of
Tab. IFA
Second estimation of Blood Haemoglobin at 20-24 weeks of gestations
Date of second Hb. Estimation
Hb in gms%
If Hb below 7 gm%,
CEmONC Centre to which referred
If Hb between 7.1 to 8.9 gms%
First dose of Inj.
Iron sucrose
Second
dose of
Inj. Iron
sucrose
Third dose
of Iron
sucrose
Fourth
dose of
Iron
sucrose
Date :
Time of
starting :
Time of
completing :
Remarks if any
Third estimation of Blood Haemoglobin at 26-30 weeks of gestation
Date of third Hb Estimation
Hb in gms%
If Hb below 7
gm%, write name
of CEmONC
Centre to which
referred
If Hb between 7.1 to 8.9 after
four doses of Inj. Iron
sucrose given during 20-24
weeks of gestation in the
current pregnancy, two
Top up doses of Inj. Iron
sucrose
If Hb. 7.1 to 8.9 and Mothers who
have not received Inj. Iron Sucrose
during 20-24 weeks of gestation in
the current pregnancy( give four
doses )
First top
up dose
Second
top up
dose
First
dose
Second
dose
Third
dose
Fourth
dose
Date
Starting
time
Ending
time
Remarks
Fourth estimation of Haemoglobin at 30-34 weeks of gestations
Date of fourth Hb estimation
Hb in gms%
If Hb below 9 gm%, write name of CEmONC
Centre to which referred
Abstract
1. Total number of IFA tablets given
2. Total number of Injection Iron Sucrose
3. Total number of units of Blood given
Pregnancy Outcome
Mother
Birth Weight of baby
Child Still birth/Preterm/ Low Birth Weight