Page Comparison

Patient Details

Encounter date

␣␣-␣␣-␣␣␣␣ 📆

163137 Encounter start date/time

Encounter Provider

Role

Encounter Location

Scheduled visit (boolean)

🔘 Yes

🔘 No

1246 Scheduled visit

• 1065 Yes

• 1066 No

Visit type

🔘 Express pharmacy pickup without clinician visit

🔘 Follow-up Visit, Regular

164181 Visit type

• 166446 Express pharmacy pickup without clinician visit

• 160523 Follow-up visit, regular

Population Category

🔘 General population

🔘 Key population

🔘 Priority population

166432 Study population type

• 166430 General population

• 166431 Target population

• 167143 Priority Population

Key Population Type

🔘 Intravenous drug user

🔘 Man who has sex with men

🔘 Prisoners

🔘 Sex worker

🔘 Transgender Persons

166433 Target population type

• 157351 Intravenous drug user

• 160578 Male who has sex with men

• 162277 In prison

• 160579 Sex worker

• 166415 Transgender status

Priority Population Type***CC

🔽 Adolescent Girls & Young Women

🔽 Client of sex worker

🔽 Fisher Folk

🔽 Long distance truck driver

🔽 Migrant Workers

🔽 Non-intravenous drug user

🔽 Refugee

🔽 Uniformed Forces

🔽 Other

5682506 Priority Population Types***

• 166043 Late adolescent/young adulthood period

• 160580 Client of sex worker

• 159674 Fisherman

• 162198 Long distance truck driver

• 169409 Migrant worker

• 166514 Non-intravenous drug user

• 164100 Refugee

• 167815 Protection services***

• 5622 Other

Complaints and History of Complaints

History of Presenting Complaints***1390 / 5219 ???

☑️ Abdominal pain

☑️ Back pain

☑️ Chest pain

☑️ Cough

☑️ Chills

☑️ Confusion

☑️ Convulsions

☑️ Depression

☑️ Diarrhea

☑️ Discharge from Penis

☑️ Dizziness and Giddiness

☑️ Ear Problem

☑️ Epigastric pain

☑️ Excessive Sweating

☑️ Facial Pain

☑️ Fever

☑️ Flank Pain

☑️ Headache

☑️ Hearing Loss

☑️ Itching

☑️ Leg Pain

☑️ Loss of Appetite

☑️ Memory Loss

☑️ Lethargy

☑️ Mouth ulceration

☑️ Muscle pain

☑️ Nausea

☑️ Neck Pain

☑️ Night sweats

☑️ Numbness of Foot

☑️ Pain in Eye

☑️ Pain in Joint

☑️ Pain in pelvis

☑️ Pain in Scrotum

☑️ Pain of Breast

☑️ Painful Mouth

☑️ Rash

☑️ Red eye

☑️ Rectal discharge

☑️ Rhinitis

☑️ Seizure

☑️ Shortness of breath

☑️ Shoulder Pain

☑️ Sore throat

☑️ Swallowing Painful

☑️ Swollen Feet

☑️ Tremor

☑️ Urinary symptoms

☑️ Vaginal bleeding

☑️ Vaginal discharge

☑️ Vision difficulties

☑️ Vomiting

☑️ Weight loss

1390 History of present illness

5219 Chief complaint

• 151 Abdominal pain

• 141631 Dysfunctional Uterine Bleeding

• 121543 Anxiety

• 148035 Back pain

• 840 Hematuria

• 117671 Hematochezia

• 131021 Pain of breast

• 120749 Chest pain

• 871 Chills

• 120345 Confusion

• 143264 Cough

• 113054 Convulsions

• 144576 Coma

• 106 Acute Coryza

• 143129 Crying Infant

• 119574 Delirium

• 119537 Depression

• 142412 Diarrhea

• 122496 Dyspnea

• 118789 Dysphagia

• 142247 Discharge from Penis

• 141830 Dizziness and Giddiness

• 141585 Ear Problem

• 141128 Epigastric pain

• 131040 Pain in Eye

• 140941 Excessive Sweating

• 114399 Facial Pain

• 162626 Intense fatigue and general weakness

• 140070 Flank Pain

• 140238 Fever

• 135462 Lymphogranuloma venereum

• 139084 Headache

• 117698 Hearing Loss

• 116214 Hypotension

• 879 Pruritus

• 116558 Pain in Joint

• 114395 Leg pain

• 116334 Lethargy

• 135595 Loss of Appetite

• 135488 Lymphadenopathy

• 121657 Memory Loss

• 111721 Mouth ulceration

• 131015 Painful Mouth

• 133028 Muscle Cramp, Nocturnal

• 133632 Muscle pain

• 121 Myalgia

• 5978 Nausea

• 133469 Neck Pain

• 133027 Night sweats

• 132653 Numbness of Foot

• 162628 Unexplained bleeding

• 125225 Swallowing painful

• 131034 Pain in pelvis

• 5953 Vision difficulties

• 512 Rash

• 127777 Red eye

• 6017 Refusal to feed

• 113224 Rhinitis

• 131032 Pain in Scrotum

• 206 Seizure

• 126535 Shoulder Pain

• 112989 Shock

• 158843 Sore throat

• 141597Dyssomnia

• 125198 Swollen Feet

• 112200 Tremor

• 160208 Urinary symptoms

• 157498 Limb weakness

• 832 Weight loss

• 123396 Vaginal discharge

• 122983 Vomiting

• 111525 Vertigo

• 5622 Other

Specify other complaints

__________________________________

160531 Chief complaint (text)

Onset Date

␣␣-␣␣-␣␣␣␣ 📆

159948 Diagnosis date

Duration (Days)

__________________________________

1731 Sign/symptom duration

Chief complaint (text)

__________________________________

160531 Chief complaint (text)

Past Medication History

Past medical & Surgical history narrative

__________________________________

160221 Past medical history added (text)

Current TPT/ TB Treatment

Currently on treatment for tuberculosis

🔘 Yes

🔘 No

🔘 Unknown

159798 Currently on tuberculosis treatment

• 1065 Yes

• 1066 No

• 1067 Unknown

Currently on tuberculosis prophylaxis treatment (TPT)

🔘 Yes

🔘 No

🔘 Unknown

166449 Currently taking tuberculosis prophylaxis

• 1065 Yes

• 1066 No

• 1067 Unknown

Previously completed Tuberculosis preventive treatment

🔘 Yes

🔘 No

🔘 Unknown

166463 Completed course of tuberculosis prophylaxis

• 1065 Yes

• 1066 No

• 1067 Unknown

Allergies & Adverse Drug Reactions

AAllergies

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Patient reports adverse drug reaction(s)?

🔘 Yes

🔘 No

🔘 Unknown

162871 Adverse event reported

• 1065 Yes

• 1066 No

• 1067 Unknown

Medicine Causing Reaction

1193 Current drugs used

Reaction

☑️ Anaphylaxis

☑️ Angioedema

☑️ Anaemia

☑️ Arrhythmia

☑️ Bronchospasm

☑️ Cough

☑️ Diarrhea

☑️ Dystonia

☑️ Flu-Like Syndrome

☑️ Flushing

☑️ Fever

☑️ GI upset***159581AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

☑️ Nausea

☑️ Hypertension

☑️ Hives

☑️ Headache

☑️ Hepatotoxicity

☑️ Hyperuricemia

☑️ Itching

☑️ Mental status change

☑️ Musculoskeletal pain

☑️ Optic Neuritis

☑️ Shortness of breath

☑️ Rash

☑️ Tendon Rupture

☑️ Visual Disturbances

☑️ Vomiting

☑️ Unknown

☑️ Other

160646 Reaction (to an allergen)

• 148888 Anaphylaxis

• 148787 Angioedema

• 121629 Anaemia

• 120148 Arrhythmia

• 108 Bronchospasm

• 143264 Cough

• 142412 Diarrhea

• 118773 Dystonia

• 137162 Influenza-like symptoms

• 140039 Flushing

• 140238 Fever

• 5978 Nausea

• 139581 GI upset ***

• 117399 Hypertension

• 111061 Hives

• 139084 Headache

• 159098 Hepatotoxicity

• 138111 Hyperuricaemia

• 879 Pruritus

• 121677 Mental status change

• 159347 Musculoskeletal pain

• 114736 Optic Neuritis

• 141600 Shortness of breath

• 512 Rash

• 113180 Rupture of Achilles tendon

• 123074 Visual disturbance

• 122983 Vomiting

• 1067 Unknown

• 5622 Other

Severity

🔘 Not graded

🔘 Mild

🔘 Moderate

🔘 Severe

🔘 Life-threatening

162760 Severity of adverse reaction

• 1067 Unknown

• 1498 Mild

• 1499 Moderate

• 1500 Severe

• 162819 Fatal

Date of Onset

160753 Date of event

Action taken

🔘 Continue drug

🔘 Dose adjusted

🔘 Discontinued

🔘 Substitution

1255 Antiretroviral plan

• 1257 Continue regimen

• 981 Dosing change

• 1260 Stop all

• 1259 Change regimen

Family History

Family History Narrative

__________________________________

160618 Family history comment

Sexual History

Sexually active?

🔘 Yes

🔘 No

🔘 Currently not sexually active

166505 Has regular sex partner

• 1065 Yes

• 1066 No

• 160573 Currently not sexually active

Sex without a condom

🔘 Yes

🔘 No

🔘 Unknown

166658 Had sex without condom

• 1065 Yes

• 1066 No

• 1067 Unknown

Recent history of a Sexually Transmitted Infection

🔘 Yes

🔘 No

🔘 Unknown

169004Sexually transmitted infection (STI) in past 6 months

• 1065 Yes

• 1066 No

• 1067 Unknown

Reproductive History

LMP***

␣␣-␣␣-␣␣␣␣ 📆

1427 Date of last menstrual period

166079 Date of last normal menstrual period

Is client pregnant?

🔘 Yes

🔘 No

🔘 Unknown

5272 Pregnancy status

• 1065 Yes

• 1066 No

• 1067 Unknown

Expected Date of Delivery (EDD)

␣␣-␣␣-␣␣␣␣ 📆

5596 Estimated date of confinement

Wants (more) children in the near future?

🔘 Yes

🔘 No

🔘 Unknown

160571 Patient wishes to get pregnant

• 1065 Yes

• 1066 No

• 1067 Unknown

Family planning status

🔘 On Family Planning

🔘 Not using Family Planning

🔘 Wants Family Planning

160653 Family planning status

• 965 Currently using birth control

• 160652 Patient not using family planning

• 1360 Requests family planning information

Current/Desired Family Planning Method (s)

🔽 Condoms

🔽 Diaphragm

🔽 Emergency contraceptive pills

🔽 Female condom

🔽 Female sterilization

🔽 Hysterectomy

🔽 Implantable contraceptive

🔽 Injectable contraceptives

🔽 Intrauterine device

🔽 Lactational amenorrhea

🔽 Levonorgestrel

🔽 Male condom

🔽 Medroxyprogesterone acetate

🔽 Natural family planning

🔽 Norplant (implantable contraceptive)

🔽 Oral contraception

🔽 Sexual abstinence

🔽 Tubal ligation procedure

🔽 Vasectomy

🔽 Other non-coded

374 Method of family planning

Current/Desired Family Planning Method (s)

☑️ Condoms

☑️ Vasectomy

374 Method of family planning

• 190 Condoms

• 1489 Vasectomy

Social History

History of Substance Use (Alcohol, Tobacco, Drugs)

🔘 Never

🔘 Current/Past use

160246 Substance use

• 1090 Never

• 1065 Yes

Do you smoke cigarettes

🔘 Never smoker

🔘 Unknown if ever smoked

🔘 Smoker

🔘 Former smoker

163201 Smoking status

• 163198 Never smoker

• 163200 Unknown if ever smoked

• 152722 Smoker

• 152807 Former smoker

Number of years smoked

159931 Duration of smoking (in years)

Number of cigarette per day

1546 Daily cigarette use

Alcohol use

🔘 Never

🔘 Currently

🔘 In the past

159449 Alcohol use status

• 1090 Never

• 159450 Currently

• 159452 In the past

Duration in Years***

1546 Daily cigarette use****

166361 Duration of alcohol use (years)

Substances abused*****

☑️ None

☑️ Barbiturate abuse

☑️ Cannabis Abuse

☑️ Cocaine abuse

☑️ Inhalant abuse

☑️ Khat abuse

☑️ Narcotic abuse

☑️ Opioid abuse

112603 Substance abuse

• 1107 None

• 121249 Barbiturate abuse

• 146504 Cannabis Abuse

• 144661 Cocaine abuse

• 116945 Inhalant abuse

• 159779 Khat abuse

• 114751 Narcotic abuse

• 114750 Opioid abuse

History of Recent Travel?

🔘 Yes

🔘 No

165656 History of recent travel in past 14 days

• 1065 Yes

• 1066 No

Subjective narrative***CC

61675c28-e628-4173-bc65-d5e0df78a6da

Immunization History

Immunizations

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Objective History

General examination findings

☑️ Normal

☑️ Cyanosis

☑️ Dehydration

☑️ Finger Clubbing

☑️ Jaundice

☑️ Lethargic

☑️ Lymph Node Axillary

☑️ Lymph Nodes Inguinal

☑️ Oral thrush

☑️ Oedema

☑️ Wasting

☑️ Nasal Flaring

☑️ Pallor

162737Physical exam outcome

• 1107 None??? why not 1115Normal

• 143050 Cyanosis

• 142630 Dehydration

• 140125 Finger Clubbing

• 136443 Jaundice

• 116334 Lethargy

• 160613 Axillary lymph node location

• 160680 Inguinal lymph node(s)

• 5334 Candidiasis, oral

• 460 Oedema

• 823 Wasting syndrome

• 1861 Nostril flaring

• 5245 Pallor

General Examination Notes

163042 General examination (text)

Systemic Examination

Physical exam outcome

🔘 Normal

🔘 Abnormal

162737 Physical exam outcome

• 1115 Normal

• 1116 Abnormal

Reviews of System

☑️ Abdominal

☑️ Cardiovascular

☑️ Central Nervous System

☑️ Head, Ear, Eye, Nose & Throat

☑️ Genitourinary

☑️ Musculoskeletal

☑️ Respiratory

☑️ Skin

159615 Review of systems

• 160947 Abdominal examination (text)

• 163046 Cardiac examination (text)

• 163109 Nervous system examination (text)

• 163045 HEENT examination (text)

• 163047 Urogenital examination (text)

• 163048 Musculoskeletal examination (text)

• 160689 Chest examination (text)

• 160981 Skin examination (text)

Abdomen findings

☑️ Abdominal distension

☑️ Abdominal mass

☑️ Splenomegaly

☑️ Hepatomegaly

☑️ Abdominal tenderness

1125 Abdominal exam findings

• 150915 Abdominal distension

• 5103 Abdominal mass

• 5009 Splenomegaly

• 5008 Hepatomegaly

• 5105 Abdominal tenderness

Abdomen findings notes

160947 Abdominal examination (text)

CVS findings

☑️ Cardiac murmur

☑️ Cardiac rub

☑️ Elevated blood pressure

☑️ Irregular heartbeat

☑️ Palpitations

1124 Cardiac exam findings

• 562 CARDIAC MURMUR (on exam)

• 130560 Pericardial friction rub

• 140147 Elevated blood pressure

• 136522 Irregular heartbeat

• 130987 Palpitations

CVS findings notes

163046 Cardiac examination (text)

CNS findings

☑️ Abnormal reflexes

☑️ Altered sensations

☑️ Brudzinski's sign

☑️ Bulging fontenelle

☑️ Confusion

☑️ Kernicterus

☑️ Limb weakness

☑️ Loss of consciousness

☑️ Stiff neck

1082 Review of systems, central nervous system

• 150817 Abnormal Reflex

• 118872 Alterations of Sensations

• 153009 Babinski Sign

• 1836 Bulging fontenelle

• 120345 Confusion

• 136282 Kernicterus not due to Isoimmunisation

• 157498 Limb weakness

• 135592 Loss of consciousness

• 112721 Stiffness of neck

CNS findings notes

163109 Nervous system examination (text)

Genitourinary findings

☑️ Bleeding

☑️ Genital rashes/Lesions

☑️ Hypospadias

☑️ Inguinal Swelling

☑️ Rectal discharge

☑️ Scrotal mass

☑️ Testicular mass

☑️ Ulceration

☑️ Urethral discharge

☑️ Vaginal discharge

☑️ Genital Warts

1126 Urogenital exam findings

• 147241 Bleeding

• 117829 Genital herpes

• 138010 Hypospadias

• 125207 Swelling of Inguinal Region

• 154311 Rectal discharge

• 113122 Scrotal Mass

• 124965 Testicular Mass

• 124087 Tropical Ulcer

• 123529 Urethrorrhoea

• 123396 Vaginal discharge

• 139505 Genital warts

Genitourinary findings notes

163047 Urogenital examination (text)

HEENT findings

☑️

☑️

☑️

☑️

☑️

☑️

☑️

☑️

1122 HEENT exam findings

HEENT findings notes

163045 HEENT examination (text)

Musculoskeletal findings

☑️ Abnormal Posture/Movement

☑️ Deformity

☑️ Pain in Joints

☑️ Heberdens nodes

☑️ Increased of local temperature

☑️ Joint crepitus

☑️ Joint stiffness

☑️ Swelling

☑️ Muscle Wasting

☑️ Muscle weakness

☑️ Pitting/Non pitting oedema

☑️ Restriction of movement

☑️ Tendon sheath crepitus

☑️ Ulcers

1128 Musculoskeletal exam findings

• 150823 Abnormal Posture

• 155871 Deformity

• 116557 Pain in Joints

• 139047 Heberden's Node

• 165282 Increased skin temperature

• 136421 Joint Crepitus

• 116554 Stiffness of joint

• 163894 Swelling

• 163851 Quadriceps muscle wasting

• 115476 Muscle Weakness

• 130166 Pitting Edema

• 135786 Limitation of Joint Movement

• 152959 Thickening of Tendon Sheath

• 123919 Ulcer

Musculoskeletal findings notes

163048 Musculoskeletal examination (text)

Respiratory findings

☑️ Reduced breathing

☑️ Bronchial breathing

☑️ Chest in-drawing

☑️ Crackles

☑️ Dullness

☑️ Grunting

☑️ Respiratory distress

☑️ Stridor

☑️ Wheezing

1123 Chest exam findings

• 164440 Breathing poorly (<30 breaths / min)

• 146893 Bronchial Breathing

• 136768 Intercostal recession

• 127640 Respiratory crackles

• 145712 Abnormal Dullness to Percussion of Chest

• 156534 Grunting baby

• 127639 Respiratory Distress

• 136790 Inspiratory Stridor

• 122864 Wheeze - rhonchi

Respiratory findings notes

160689 Chest examination (text)

Skin findings

☑️ Abscess

☑️ Hair Loss

☑️ Itching

☑️ Kaposis Sarcoma

☑️ Swelling/Growth

☑️ Skin eruptions/Rashes

☑️ Ulcer

1120 Skin exam findings

• 150555 Abscess of skin and subcutaneous tissue

• 135591 Loss of Hair

• 136455 Itching

• 507 Kaposi's sarcoma of skin

• 125201 Swelling of Skin

• 1249 Papular pruritic eruption

• 123919 Ulcer

Skin findings notes

160981 Skin examination (text)

WHO HIV Stage

Current WHO HIV stage

🔘 Unknown

🔘 WHO stage 1

🔘 WHO stage 2

🔘 WHO stage 3

🔘 WHO stage 4

5356 Current WHO HIV stage

• 1067 Unknown

• 1204 WHO stage 1 adult

• 1205 WHO stage 2 adult

• 1206 WHO stage 3 adult

• 1207 WHO stage 4 adult

Nutritional Assessment

Nutritional status

🔘 Not done

🔘 Normal

🔘 Severe acute malnutrition

🔘 Moderate acute malnutrition

🔘 Obesity

167392 Nutritional status

• 1118 Not done

• 1115 Normal

• 163302 Severe acute malnutrition

• 163303 Moderate acute malnutrition

• 115115 Obesity

Nutritional interventions provided

🔘 Yes

🔘 No

🔘 Unknown

1380 Nutrition counseling

• 1065 Yes

• 1066 No

• 1067 Unknown

Nutritional support

☑️ Counseling about infant feeding practices

☑️ Food support

☑️ Micronutrient support

☑️ Therapeutic feeding

☑️ Other (specify)

☑️ None

5484 Nutritional support

• 161651 Counseling about infant feeding practices

• 161648 Food support

• 161649 Micronutrient support

• 161650 Therapeutic feeding

• 5622 Other

• 1107 None

Nutritional plan (text)

163189 Nutritional plan (text)

TB Screening

TB screening done?

🔘 Yes

🔘 No

🔘 Unknown

164800 Screened for tuberculosis

• 1065 Yes

• 1066 No

• 1067 Unknown

TB Intensive Case Finding

☑️ Night sweats

☑️ Failure to Gain Weight

☑️ Fever lasting more than three weeks

☑️ Cough lasting more than 2 weeks

☑️ Weight Loss (Abnormal weight loss)

☑️ None

Peads TB Intensive Case Finding

☑️ History of contact with a person with TB

☑️ Fever lasting more than three weeks

☑️ 159800 Tuberculosis, review of screening questions

• 133027 Night sweats

• 140707 Failure to Gain Weight

• 140238 Fever

• 159799 Cough lasting more than 2 weeks

☑️ Failure to Gain Weight

• 1858 Recent weight loss

• 1107 None

TB screening outcome

🔘 Negative

🔘 Positive (Presumptive TB)

Evaluated for tuberculosis prophylaxis

🔘 Not applicable

🔘 Yes

🔘 No

Tuberculosis prophylaxis plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Stop all

Tuberculosis preventive treatment regimen

🔽 1 HP Isoniazide + Rifapentine prophylaxis

🔽 3HP Rifapentine + Isoniazid

🔽 3HR Isoniazid+Rifampicin prophylaxis

🔽 4R Rifampicin Monotherapy prophylaxis

🔽 6H Isoniazid prophylaxis

🔽 9H Isoniazid prophylaxis

Date tuberculosis prophylaxis started

␣␣-␣␣-␣␣␣␣ 📆

Tuberculosis Preventive Treatment adherence

🔘 Good

🔘 Poor

🔘 Fair

🔘 Unknown

Date tuberculosis prophylaxis ended

␣␣-␣␣-␣␣␣␣ 📆

Reason tuberculosis prophylaxis stopped

🔘 Completed

🔘 Toxicity, drug

🔘 Tuberculosis

🔘 Other non-coded

Tuberculosis treatment plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Change regimen

🔘 Dosing Change

🔘 Stop all

Tuberculosis drug treatment start date

␣␣-␣␣-␣␣␣␣ 📆

Tuberculosis treatment end date

␣␣-␣␣-␣␣␣␣ 📆

Action taken - Presumptive TB

☑️ GeneXpert MTB/Rif Ordered

☑️ Sputum for acid fast bacilli ordered

☑️ X-ray, chest ordered

Notes

__________________________________

Physical/Systemic Exam

General Exam (On Exam)

☑️ Anaemia

☑️ Clubbing

☑️ Candidiasis, oral

☑️ Cyanosis

☑️ Dehydration

☑️ Jaundice

☑️ Lymphadenopathy

☑️ Oedema

☑️ Lethargy

☑️ Pallor

☑️ Severely wasted

☑️ Normal

☑️ Not assessed

☑️ Other non-coded

General Examination Notes

__________________________________

Lympadenopathy

☑️ Submandibular

☑️ Cervical

☑️ Supraclavicular

☑️ Axillary

☑️ Inguinal

HEENT (head, eyes, ears, nose, and throat)

🔘 Normal

🔘 Abnormal

🔘 Not assessed

HEENT examination findings (Text)

__________________________________

Respiratory Systems review

🔘 Normal

🔘 Abnormal

🔘 Not assessed

Respiratory System Findings (Text)

__________________________________

Cardiovascular Systems review

🔘 Normal

🔘 Abnormal

🔘 Not assessed

Cardiovascular examination finding (Text)

__________________________________

Gastrointestinal System review

🔘 Normal

🔘 Abnormal

🔘 Not assessed

Abdominal examination finding (Text)

__________________________________

Central nervous system review

🔘 Normal

🔘 Abnormal

🔘 Not assessed

CNS examination finding (text)

__________________________________

Musculoskeletal system review

🔘 Normal

🔘 Abnormal

🔘 Not assessed

Musculoskeletal examination finding (Text)

__________________________________

Genito-urinary system - ROS/PE

🔘 Normal

🔘 Abnormal

🔘 Not assessed

Genito-urinary system examination finding (text)

__________________________________

Screened for STIs in current visit

🔘 Yes

🔘 No

🔘 Unknown

STI screening findings

🔘 Genital Sore

🔘 Lower abdominal pain

🔘 Scrotal Mass

🔘 Urethral Discharge

🔘 Vaginal discharge

🔘 Normal

Current WHO HIV stage

🔘 WHO stage 1 peds

🔘 WHO stage 2 peds

🔘 WHO stage 3 peds

🔘 WHO stage 4 peds

🔘 WHO stage 1 adult

🔘 WHO stage 2 adult

🔘 WHO stage 3 adult

🔘 WHO stage 4 adult

🔘 Unknown

Nutritional status

🔘 Not done

🔘 Normal

🔘 Severe acute malnutrition

🔘 Moderate acute malnutrition

🔘 Obesity

Nutritional interventions provided

🔘 Yes

🔘 No

🔘 Unknown

Nutritional support

☑️ Counseling about infant feeding practices

☑️ Food support

☑️ Micronutrient support

☑️ Therapeutic feeding

☑️ Other (specify)

☑️ None

Nutritional plan (text)

__________________________________

Management

New/Active opportunistic infection

🔘 None

🔘 Opportunistic Infectious Present

🔘 Unknown

Current opportunistic infections

☑️ Candidiasis, oral

☑️ Cerebral Cryptococcosis

☑️ Cervical Intraepithelial Neoplasm

☑️ Coccidioidomycosis

☑️ Cytomegalovirus infection

☑️ Encephalopathy

☑️ Hepatitis B

☑️ Hepatitis C virus infection

☑️ Herpes simplex type 2

☑️ Herpes zoster

☑️ Histoplasmosis

☑️ Infection due to Candida Albicans

☑️ Kaposi sarcoma oral

☑️ Leukoencephalopathy

☑️ Malignant Lymphoma

☑️ Meningitis, cryptococcal

☑️ Mycobacterium tuberculosis

☑️ Pneumocystis carinii pneumonia

☑️ Pneumonia

☑️ Pulmonary Cryptococcosis

☑️ Recurrent Upper Respiratory Tract Infection

☑️ Salmonella Septicaemia

☑️ Toxoplasmosis

☑️ Wasting syndrome

Pneumocystis pneumonia prophylaxis plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Change regimen

🔘 Stop all

PCP prophylaxis start date

␣␣-␣␣-␣␣␣␣ 📆

PCP prophylaxis regimen

🔘 Sulfamethoxazole / trimethoprim

🔘 Dapsone

PCP regimen adherence

🔘 Good

🔘 Fair

🔘 Poor

🔘 Unknown

Reason for stopping PCP prophylaxis

🔘 CD4 count greater than 15%

🔘 CD4 count greater than 200

🔘 Toxicity, drug

🔘 Other non-coded

Cryptococcal prophylaxis plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Stop all

Fluconazole start date

␣␣-␣␣-␣␣␣␣ 📆

Fluconazole stop date

␣␣-␣␣-␣␣␣␣ 📆

HAART adherence assessment

🔘 Good

🔘 Fair

🔘 Poor

🔘 Unknown

Reason for Fair/Poor adherence to HAART

🔽 Alcohol abuse

🔽 Concerned about privacy/stigma

🔽 Depression

🔽 Felt better and stopped taking medication

🔽 Felt too ill to take medication

🔽 Forgot to take medication

🔽 Lost or ran out of medication

🔽 Pill burden

🔽 Shares medications with others

🔽 Toxicity, drug

🔽 Transport problems

🔽 Other non-coded

Labs and Drugs Orders

Clinical Notes

__________________________________

ARV dispensing quantity (in days)

__________________________________

Patient referred for other services

🔘 Yes

🔘 No

Reason for referral

☑️

☑️

☑️

☑️

☑️

160108 Screening test result, tuberculosis

• 664 Negative

• 703 Positive

Action taken - Presumptive TB

☑️ GeneXpert MTB/Rif Ordered

☑️ Sputum for acid fast bacilli ordered

☑️ X-ray, chest ordered

166937 Care management plan

• 164945 GeneXpert MTB/Rif Lab set

• 307 Sputum for acid fast bacilli

• 12 X-ray, chest

Laboratory and Diagnostic Tests

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1238 Medical record observations

Assessment

Diagnosis & Problem List

159947 Visit Diagnoses

Diagnosis

1284 Problem list

Diagnosis certainty

🔽 Presumptive diagnosis

🔽 Provisonal diagnosis

🔽 Confirmed diagnosis

🔽 Final diagnosis

159394 Diagnosis certainty

• 159393 Presumed diagnosis

• 160249 Provisional diagnosis

• 159392 Confirmed diagnosis

• 160250 Final diagnosis

Diagnosis order

🔘 Primary

🔘 Secondary

159946 Diagnosis order

• 159943 Primary

• 159944 Secondary

Diagnosis non-coded

161602 Diagnosis or problem, non-coded

Problem List

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Treatment/Management Plan

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Tuberculosis Preventive Treatment (TPT)

Evaluated for tuberculosis prophylaxis

🔘 Not applicable

🔘 Yes

🔘 No

162275 Evaluated for tuberculosis prophylaxis

• 1175 Not applicable

• 1065 Yes

• 1066 No

Tuberculosis prophylaxis plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Stop all

1265 Tuberculosis prophylaxis plan

• 1107 None

• 1256 Start drugs

• 1257 Continue regimen

• 1260 Stop all

Tuberculosis preventive treatment regimen

🔽 1 HP Isoniazid + Rifapentine prophylaxis

🔽 3HP Rifapentine + Isoniazid

🔽 3HR Isoniazid+Rifampicin prophylaxis

🔽 4R Rifampicin Monotherapy prophylaxis

🔽 6H Isoniazid prophylaxis

🔽 9H Isoniazid prophylaxis

90c9e554-b959-48e6-90d5-8d595a074c86

• 169413 Isoniazid + rifapentine prophylaxis - one month (1HP)

• 169415 Isoniazid + Rifapentine prophylaxis - three months (3HP)

• 169412Isoniazid + rifampicin prophylaxis - three months (3HR)

• 169414 Rifampicin monotherapy prophylaxis - four months (4R)

• 169411 Isoniazid prophylaxis - six months (6H)

• 169410 Isoniazid prophylaxis - nine months (9H)

Date tuberculosis prophylaxis started

␣␣-␣␣-␣␣␣␣ 📆

162320 Date started on tuberculosis prophylaxis

Tuberculosis Preventive Treatment adherence

🔘 Good

🔘 Poor

🔘 Fair

🔘 Unknown

161653 Isoniazid adherence

• 159405 Good

• 159407 Poor

• 159406 Fair

• 1067 Unknown

Date tuberculosis prophylaxis ended

␣␣-␣␣-␣␣␣␣ 📆

163284 Date tuberculosis prophylaxis ended

Reason tuberculosis prophylaxis stopped

🔘 Completed

🔘 Toxicity, drug

🔘 Tuberculosis

🔘 Other non-coded

1266 Reason tuberculosis prophylaxis stopped

• 1267 Completed

• 102 Toxicity, drug

• 112141 Tuberculosis

• 5622 Other

Treatment of TB

Tuberculosis treatment plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Change regimen

🔘 Dosing Change

🔘 Stop all

1268 Tuberculosis treatment plan

• 1107 None

• 1256 Start drugs

• 1257 Continue regimen

• 1259 Change regimen

• 981 Dosing change

• 1260 Stop all

Tuberculosis drug treatment start date

␣␣-␣␣-␣␣␣␣ 📆

1113 Tuberculosis drug treatment start date

Tuberculosis treatment end date

␣␣-␣␣-␣␣␣␣ 📆

159431 Tuberculosis treatment end date

Prevention of opportunistic infections - PCP

Pneumocystis pneumonia prophylaxis plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Change regimen

🔘 Stop all

1261 PCP prophylaxis plan

• 1107 None

• 1256 Start drugs

• 1257 Continue regimen

• 1259 Change regimen

• 1260 Stop all

PCP prophylaxis start date

␣␣-␣␣-␣␣␣␣ 📆

164361Cotrimoxazole prophylaxis start date

PCP prophylaxis regimen

🔘 Sulfamethoxazole / trimethoprim

🔘 Dapsone

1109Patient reported current PCP prophylaxis

• 105281 Sulfamethoxazole / trimethoprim

• 74250 Dapsone

PCP regimen adherence

🔘 Good

🔘 Fair

🔘 Poor

🔘 Unknown

166462 Pneumocystis carinii pneumonia prophylaxis adherence

• 159405 Good

• 159406 Fair

• 159407 Poor

• 1067 Unknown

Reason for stopping PCP prophylaxis

🔘 CD4 count greater than 15%

🔘 CD4 count greater than 200

🔘 Toxicity, drug

🔘 Other non-coded

1262 Reason PCP prophylaxis stopped

• 982 CD4 count greater than 15%

• 1254 CD4 count greater than 200

• 102 Toxicity, drug

• 5622 Other

Prevention of Opportunistic Infections - Cryptococcosis

Cryptococcal prophylaxis plan

🔘 None

🔘 Start drugs

🔘 Continue regimen

🔘 Stop all

1277 Cryptococcal treatment plan

• 1107 None

• 1256 Start drugs

• 1257 Continue regimen

• 1260 Stop all

ART Adherence

HAART adherence assessment

🔘 Good

🔘 Fair

🔘 Poor

🔘 Unknown

1164 Antiretroviral adherence in past week

• 159405 Good

• 159406 Fair

• 159407 Poor

• 1067 Unknown

Reason for Fair/Poor Adherence to HAART

🔽 Alcohol abuse

🔽 Concerned about privacy/stigma

🔽 Depression

🔽 Felt better and stopped taking medication

🔽 Felt too ill to take medication

🔽 Forgot to take medication

🔽 Lost or ran out of medication

🔽 Pill burden

🔽 Shares medications with others

🔽 Toxicity, drug

🔽 Transport problems

🔽 Other non-coded

160582 Reason for poor treatment adherence

• 121725 Alcohol abuse

• 160589 Concerned about privacy/stigma

• 119537 Depression

• 160586 Felt better and stopped taking medication

• 160585 Felt too ill to take medication

• 160587 Forgot to take medication

• 160584 Lost or ran out of medication

• 160588 Pill burden

• 160583 Shares medications with others

• 102 Toxicity, drug

• 820 Transport problems

• 5622 Other

Referrals

Referrals ordered

🔽 None

🔽 Adherence counseling

🔽 Alcohol counseling

🔽 Dental care referral

🔽 Diagnostic testing and counseling for HIV

🔽 Disclosure counseling

🔽 Family planning services

🔽 Health center hospital

🔽 Health clinic/post

🔽 Hospital

🔽 Inpatient care or hospitalization

🔽 Maternal and child health program

🔽 Mental health services

🔽 Nutritional support

🔽 Obstetrics and gynecology department

🔽 Ophthalmology referral

🔽 Postnatal care referral

🔽 Prenatal care referral

🔽 Private health care clinic/facility

🔽 Private home-based care

🔽 Psychosocial counseling

🔽 Referral for antiretroviral therapy

🔽 Referral for imaging study

🔽 Referral for opportunistic infection treatment

🔽 Referral for pregnancy termination

🔽 Sexually transmitted infection program/clinic

🔽 Social support services

🔽 Surgical Outpatient Department

🔽 Tobacco use counseling

🔽 Tuberculosis Treatment or DOT Program

🔽 Voluntary counseling and testing for HIV

🔽 Other non-coded

1272 Referrals ordered

Reason for referral (text)

164359 Reason for referral (text)

Follow-up

Next Appointment Date

␣␣-␣␣-␣␣␣␣ 📆

5096 Return visit date

Date medication refill is due

␣␣-␣␣-␣␣␣␣ 📆

162549 Date medication refills due

General Encounter Notes

General Note

162169 Text of encounter note