Table 1 Case record form

Study number:

Demographic data:

Age:

Gender:

Inpatient number:

Date and time of admission:

Contact number:

Weight on admission:

Indication for admission:

Diagnosis on admission:

Final Diagnosis:

Total no of days of PICU stay:

Mechanical ventilation:

Any Government Programme under which patient is enrolled:

Actual medical cost incurred during PICU stay:

D1

D2

D3

D4

D5

Total

Medicine

Investigations

Consultation fees

PICU Charges

Others

Total

Approximate non-medical cost incurred post-hospitalization:

D1

D2

D3

D4

D5

Total

Travel

Meals

Accommodation

Communication

Caring for Siblings

Any other Incidental expenses

Total

Total Out Of Pocket Expenses=

[Actual medical cost+ non-medical cost] =

Total no. of days family member had to stay away from work=

Monthly income of the family=

The Group under which the Family falls depending on Monthly Income =

Average daily expenditure = Medical OOPE/total days of PICU stay=

Estimated Daily Budget=

Percentage Daily Expenditure /Daily Budget =