Record ID
Serial No
Research Assistant initials
Admission ward
Time period
Month of the year
Day of the week
Date of admission
Patient had accident
Area of accident
Month of Accident
Day of accident
Time of accident
Date of accident/injury
Type of Health Facility
Health Facility Tier
Explain RTA
Explain assault
Explain fall
Explain gunshot
Explain stab wound
Explain others
B) Why did you bypass the facility? (choice=Human resource)
B) Why did you bypass the facility? (choice=Infrastructure)
B) Why did you bypass the facility? (choice=Equipment and implants availability)
B) Why did you bypass the facility? (choice=Patients factors and preference)
B) Why did you bypass the facility? (choice=Financial)
B) Why did you bypass the facility? (choice=Not well defined)
B) Why did you bypass the facility? (choice=Others)
Explain human resource
Explain infrastructure
Explain equipment and implants availability
Explain patient factors and preference
Explain financial
b) County of Residence
b) Area/Estate of residence
Specify insurance
Age category
18. Smoking
19.Alcohol
Specify Humerus a
Specify humerus b
Specify humerus a ICD 10
Specify humerus b ICD 10
Specify Radius/ulnar a
Specify Radius/ulnar a ICD10
Specify Radius/ulnar b
Specify Radius/ulnar b ICD10
Specify hand fracture a
Hand fracture a ICD10
Specify hand fracture b
Hand fracture b ICD10
Specify Hand fracture c
Hand fracture c ICD10
Specify Hand fracture d
Hand fracture d ICD10
Specify femur fracture a
Specify femur fracture a ICD10
Specify femur fracture b
Specify femur fracture b ICD10
Specify Tibia/Fibula fracture a
Specify Tibia/Fibula fracture a ICD10
Specify Tibia/Fibula fracture b
Specify Tibia/Fibula fracture b ICD10
Specify Tibia/Fibula fracture c
Specify Tibia/Fibula fracture c ICD10
Specify Foot fracture a
Foot fracture a ICD10
Foot fracture b
Foot fracture b ICD10
Foot fracture c
Foot fracture c ICD10
Specify Pelvic Fractures a
Specify Pelvic Fractures a ICD10
Specify Pelvic Fractures b
Specify Pelvic Fractures b ICD10
Specify Acetabular fracture a
Specify Acetabular fracture a ICD10
Specify Spine fracture a
Specify Spine fracture a ICD10
Specify Spine fracture b
Specify Spine fracture b ICD10
Specify Ankle dislocation a
Specify Ankle dislocation a ICD10
Specify Ankle dislocation b
Specify Ankle dislocation b ICD10
Specify Knee dislocation a
Specify Knee dislocation a ICD10
Specify Knee dislocation b
Specify Knee dislocation b ICD10
Specify elbow dislocation a
Specify elbow dislocation a ICD10
Specify shoulder dislocation a
Specify shoulder dislocation a ICD10
Specify shoulder dislocation b
Specify shoulder dislocation b ICD10
Specify wrist dislocation a
Specify wrist dislocation a ICD10
Specify hip dislocation a
Specify hip dislocation a ICD10
Specify Other Non_Trauma Orthopaedic Disorders a
Other Non_Trauma Orthopaedic Disorders ICD a
Specify Other Non_Trauma Orthopaedic Disorders b
Other Non_Trauma Orthopaedic Disorders ICD b
Specify Other Non_Trauma Orthopaedic Disorders c
Other Non_Trauma Orthopaedic Disorders ICD c
Specify co-morbidity a
co-morbidity a ICD10
Specify co-morbidity b
Co-morbidity b I CD 10
Specify co-morbidity c
Co-morbidity c ICD10
Specify co-morbidity d
Co-morbidity d ICD10
Complete?