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CPAP Patient Registry

If the patient was treated with CPAP during his/her hospital stay, please fill out the CPAP Patient Registry form below.

Health care facility

Name of hospital

Rundu State Hospital

Onandjokwe State Hospital

Patient identification

First Name

Family name

Sex

male

female

Date of birth

Europe/Berlin

Estimated gestational age at birth (weeks)

Birth weight (grams)

Diagnoses

Main diagnosis I

Main diagnosis II

Main diagnosis III

Chest X-ray obtained

yes

no

If yes, main findings (please, be specific)

Respiratory therapies

Surfactant given

yes

no

Type of CPAP device used

Pumani

Dolphine

both

Date when put on CPAP

Europe/Berlin

Date when CPAP stopped

Europe/Berlin

Days on CPAP

Complications while on CPAP (describe in detail)

Outcome

Please, select final outcome at discharge

Survived

Died

If patient died, date of death

Europe/Berlin

If patient died, main causes of death (please, describe in detail)

Additional comments

Please, describe in detail

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