Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia
Version 3.1 (Dec09)
Appendix 9.3: SAMPLE MALE CIRCUMCISION ADVERSE EVENT FORM
1. Client’s name: ____________________________________________________
2. a: Date of visit: / / (dd/mm/yy)
b: Date of circumcision: / / (dd/mm/yy)
3. Patient’s ID Number: M C -
Instructions: Check (√ ) appropriate box for any adverse events
Adverse event Description Severity
A. During surgery
Pain
Excessive
bleeding
Anaestheticrelated
event
Excessive skin
removed
Damage to the
penis
3 or 4 on pain scale Mild
5 or 6 on pain scale Moderate
7 on pain scale Severe
More bleeding than usual, but easily controlled Mild
Bleeding that requires pressure dressing to control Moderate
Blood transfusion or transfer to another facility Severe
required
Palpitations, vaso-vagal reaction or emesis
Mild
Reaction to anaesthetic requiring medical treatment Moderate
in clinic, but not transfer to another facility
Anaphylaxis or other reaction requiring transfer to Severe
another facility
Adds time or material needs to the procedure, but Mild
does not result in any discernible adverse condition
Skin is tight, but additional operative work not Moderate
necessary
Requires re-operation or transfer to another facility to Severe
correct the problem
Mild bruising or abrasion, not requiring treatment Mild
Bruising or abrasion of the glans or shaft of the penis Moderate
requiring pressure dressing or additional surgery to
control
Part or all of the glans or shaft of the penis severed Severe
√
Treatment provided: ______________________________________________________
Treatment outcome: Adverse event completely resolved
Adverse event partially resolved
Adverse event unchanged
Was patient referred Yes No If yes, to where __________________________
Record keeping, monitoring, evaluation and supervision Chapter 9-11