Questions | Concepts | |
|---|---|---|
Patient Details | ||
Encounter date ␣␣-␣␣-␣␣␣␣ 📆 | ||
Scheduled visit 🔘 Yes 🔘 No | ||
Visit type 🔘 Express pharmacy pickup without clinician visit 🔘 Follow-up Visit, Regular | ||
Presenting Complaints | ||
Any presenting complaints? 🔘 Yes 🔘 No | ||
Presenting complaints ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ | ||
Presenting Complaints Notes __________________________________ | ||
Conditions List  | ||
Allergies  | ||
Patient reports adverse drug reaction(s)? 🔘 Yes 🔘 No 🔘 Unknown | ||
OBGYN History | ||
Current menstruation status 🔘 Amenorrhea 🔘 Currently pregnant 🔘 Menstruating | ||
LMP ␣␣-␣␣-␣␣␣␣ 📆 | ||
Intend to conceive in the next three months? 🔘 Yes 🔘 No 🔘 Unknown | ||
Breastfeeding 🔘 Yes 🔘 No 🔘 Unknown | ||
Family planning method 🔘 Patient not using family planning 🔘 Currently using birth control 🔘 Requests family planning information | ||
Preferred family planning method 🔽 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 | ||
Reason not on family planning 🔽 Currently not sexually active 🔽 Patient thinks she can't get pregnant 🔽 Patient wishes to get pregnant | ||
EDD ␣␣-␣␣-␣␣␣␣ 📆 | ||
Gestational age (weeks) | ||
Antenatal profile done 🔘 Yes 🔘 No | ||
Screened for cervical cancer during this visit 🔘 Cervical cancer screening not performed 🔘 Cervical cancer screening performed | ||
Date last screened for cervical cancer ␣␣-␣␣-␣␣␣␣ 📆 | ||
Cervical cancer screening method ☑️ Colposcopy ☑️ Human Papillomavirus test ☑️ Papanicolaou smear ☑️ Visual Inspection of the Cervix with Acetic Acid (VIA) ☑️ Visual Inspection of the Cervix with Lugol’s Iodine (VILI) | ||
Treatment of cervical pre-cancer lesions 🔘 Cold knife cone biopsy of cervix 🔘 Cryosurgery of lesion of cervix 🔘 Hysterectomy 🔘 Loop electrosurgical excision procedure of cervix 🔘 Thermocauterization of cervix 🔘 Other non-coded 🔘 None | ||
Tuberculosis | ||
Currently on treatment for tuberculosis 🔘 Yes 🔘 No 🔘 Unknown | ||
Currently on tuberculosis prophylaxis treatment (TPT) 🔘 Yes 🔘 No 🔘 Unknown | ||
Previously completed Tuberculosis preventive treatment 🔘 Yes 🔘 No 🔘 Unknown | ||
TB screening done? 🔘 Yes 🔘 No 🔘 Unknown | ||
Adult TB Intensive Case Finding ☑️ Night sweats ☑️ 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 ☑️ Cough lasting more than 2 weeks ☑️ Failure to Gain Weight ☑️ 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 ☑️ ☑️ ☑️ ☑️ ☑️ | ||
Referral comments __________________________________ | ||
Next Appointment Date ␣␣-␣␣-␣␣␣␣ 📆 | ||
Date medication refill is due ␣␣-␣␣-␣␣␣␣ 📆 | ||
Attending clinician's name __________________________________ |
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