Emergency Management Apps

Ebola Infection Data Form

One of the fastest ways to prevent the spread of deadly diseases such as Ebola is to catalog instances on a map. Emergency planners can use this geospatial information to allocate resources and prevent loss of life. ISARIC https://isaric.tghn.org/ and ISARIC’s partners and collaborators have developed a number of data tools to support clinical research and data collection during and following Ebola outbreaks, all of which are freely available for download and adaption from https://isaric.tghn.org/protocols/ebola-data-tools/. This app is a modification of the “Ebola Infection Data Forms with CDASH Annotation” document, for use with Fulcrum.

Ebola Infection Data Form iPhone, iPad Ebola Infection Data Form Android Ebola Infection Data Form Web, Desktop
Ebola Infection Data Form

Patient Identification Number

Admission

Date of admission to this facility

Facility name

Facility country

Patient Surname

Other names

Date of birth

Estimated Age

(if<2years) how many months

Male or Female

Weight in kg

Weight Measured or Estimated

Is the patient pregnant

Gestation age of fetus (nearest week)

Date of onset of first/earliest symptom

Ebolavirus PCR - Complete with all results

Sample Collection

Time of collection

Sample type

Lab Identifier

Test kit

Result

CT value

OUTCOME

Final EVD diagnosis

What was the patient's outcome

Date of outcome

If FEMALE did the patient give birth within the previous 6 weeks?

What was the outcome of the pregnancy

Date of pregnancy outcomerpdat

Observations and Hydration

Date

Time

Temperature

Respiratory Rate

Heart Rate

Systolic Blood Pressure

Diastolic Blood Pressure

LOWEST Consciousness

Weakness/asthenia

Pain

Nausea

Vomiting

Diarrhea

Unusual Bleeding/bruising

Anorexia/dysphagia/poor intake

Signs of dehydration

Signs of Shock

Anuria

Disorientation

Agitation

Seizure

Patient status/group

Hydration: Since the previous assessment, has the patient received:

Enteral fluids

Parenteral fluids

Method of parenteral fluid administered

Parenteral fluid given

Daily Medications & Blood Products

Date when drugs are administered

Drug/Blood Product

Route

Dose

Times Given

Time #1

Time #2

Time #3

Time #4

Time #5

Laboratory Results

Date

Sodium/Na+

Potassium/K+

Blood Urea Nitrogen

Creatinine

Chloride/CI

Bicarbonate/HCO3-

Calcium (total)/Ca++

Glucose

Lactate

Amylase

Bilirubin (total)

AST/SGOT

ALT/SGPT

Albumin

Haemoglobin

Haematocrit

WBC count

Platelets

D-dimer

APTT

PT

INR

Creatine kinase