Questions | Concepts |
|---|---|
Patient Details | |
Encounter date ␣␣-␣␣-␣␣␣␣ 📆 | |
Encounter Provider | |
Role | |
Scheduled visit (boolean) 🔘 Yes 🔘 No | |
Visit type 🔘 Express pharmacy pickup without clinician visit 🔘 Follow-up Visit, Regular | |
Population Category 🔘 General population 🔘 Key population 🔘 Priority population | |
Key Population Type 🔘 Intravenous drug user 🔘 Man who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons | |
Priority Population Type 🔽 Adolescent Girls & Young Women 🔽 Client of sex worker 🔽 Fisher Folk 🔽 Long distance truck driver 🔽 Migrant Workers 🔽 Non-intravenous drug user 🔽 Refugee 🔽 Uniformed Forces 🔽 Other | |
Complaints and History of Complaints | |
|
|
History of Presenting Complaints ☑️ 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 |
Onset Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Duration (Days) __________________________________ | |
Chief complaint (text) __________________________________ | |
Past Medication History | |
Past medical & Surgical history narrative __________________________________ | |
Current TPT/ TB Treatment | |
Currently on treatment for tuberculosis | |
Currently on tuberculosis prophylaxis treatment (TPT) | |
Previously completed Tuberculosis preventive treatment | |
Allergies & Adverse Drug Reactions | |
AAllergies | workspace-launcher |
Patient reports adverse drug reaction(s)? 🔘 Yes 🔘 No 🔘 Unknown | |
Medicine Causing Reaction | |
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)
|
Severity 🔘 Not graded 🔘 Mild 🔘 Moderate 🔘 Severe 🔘 Life-threatening | |
Date of Onset | |
Action taken 🔘 Continue drug 🔘 Dose adjusted 🔘 Discontinued 🔘 Substitution | |
Family History | |
Family History Narrative | |
Sexual History | |
Sexually active? 🔘 Yes 🔘 No 🔘 Currently not sexually active | |
Sex without a condom 🔘 Yes 🔘 No 🔘 Unknown | |
Recent history of a Sexually Transmitted Infection 🔘 Yes 🔘 No 🔘 Unknown | |
Reproductive History*** | |
Social History | |
History of Substance Use (Alcohol, Tobacco, Drugs) 🔘 Never 🔘 Current/Past use | |
Do you smoke cigarettes 🔘 Never smoker 🔘 Unknown if ever smoked 🔘 Smoker 🔘 Former smoker | |
Number of years smoked | |
Number of cigarette per day | |
Alcohol use 🔘 Never 🔘 Currently 🔘 In the past | |
Duration in Years**** | |
Substances abused***** ☑️ None ☑️ Barbiturate abuse ☑️ Cannabis Abuse ☑️ Cocaine abuse ☑️ Inhalant abuse ☑️ Khat abuse ☑️ Narcotic abuse ☑️ Opioid abuse | |
History of Recent Travel? 🔘 Yes 🔘 No | |
Subjective narrative*** | 61675c28-e628-4173-bc65-d5e0df78a6da |
Immunization History | |
Immunizations | workspace-launcher |
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 | |
General Examination Notes | |
Systemic Examination | |
Physical exam outcome 🔘 Normal 🔘 Abnormal | |
Reviews of System ☑️ Abdominal ☑️ Cardiovascular ☑️ Central Nervous System ☑️ Head, Ear, Eye, Nose & Throat ☑️ Genitourinary ☑️ Musculoskeletal ☑️ Respiratory ☑️ Skin | |
Abdomen findings ☑️ Abdominal distension ☑️ Abdominal mass ☑️ Splenomegaly ☑️ Hepatomegaly ☑️ Abdominal tenderness | |
Abdomen findings notes | |
CVS findings ☑️ Cardiac murmur ☑️ Cardiac rub ☑️ Elevated blood pressure ☑️ Irregular heartbeat ☑️ Palpitations | |
CVS findings notes | |
CNS findings ☑️ Abnormal reflexes ☑️ Altered sensations ☑️ Brudzinski's sign ☑️ Bulging fontenelle ☑️ Confusion ☑️ Kernicterus ☑️ Limb weakness ☑️ Loss of consciousness ☑️ Stiff neck | |
CNS findings notes | |
Genitourinary findings ☑️ Bleeding ☑️ Genital rashes/Lesions ☑️ Hypospadias ☑️ Inguinal Swelling ☑️ Rectal discharge ☑️ Scrotal mass ☑️ Testicular mass ☑️ Ulceration ☑️ Urethral discharge ☑️ Vaginal discharge ☑️ Genital Warts | |
Genitourinary findings notes | |
HEENT findings ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ | |
HEENT findings notes | |
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 |
Musculoskeletal findings notes | |
Respiratory findings ☑️ Reduced breathing ☑️ Bronchial breathing ☑️ Chest in-drawing ☑️ Crackles ☑️ Dullness ☑️ Grunting ☑️ Respiratory distress ☑️ Stridor ☑️ Wheezing | |
Respiratory findings notes | |
Skin findings ☑️ Abscess ☑️ Hair Loss ☑️ Itching ☑️ Kaposis Sarcoma ☑️ Swelling/Growth ☑️ Skin eruptions/Rashes ☑️ Ulcer | |
Skin findings notes | |
WHO HIV Stage | |
Current WHO HIV stage 🔘 Unknown 🔘 WHO stage 1 🔘 WHO stage 2 🔘 WHO stage 3 🔘 WHO stage 4 | |
Nutritional Assessment | |
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) | |
TB Screening | |
TB screening done? 🔘 Yes 🔘 No 🔘 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 | |
TB screening outcome 🔘 Negative 🔘 Positive (Presumptive TB) | |
Action taken - Presumptive TB ☑️ GeneXpert MTB/Rif Ordered ☑️ Sputum for acid fast bacilli ordered ☑️ X-ray, chest ordered | |
Laboratory and Diagnostic Tests | |
Order Basket Launcher | |
Upload File or Image | |
Assessment | |
Diagnosis & Problem List | |
Diagnosis | |
Diagnosis certainty 🔽 Presumptive diagnosis 🔽 Provisonal diagnosis 🔽 Confirmed diagnosis 🔽 Final diagnosis | |
Diagnosis order 🔘 Primary 🔘 Secondary | |
Diagnosis non-coded | |
Problem List | Workspace-launcher |
Treatment/Management Plan | |
TB | |
Prevention of opportunistic infections - PCP | |
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 (2 similar CIEL concepts???) 🔘 Other non-coded | |
Prevention of Opportunistic Infections - Cryptococcosis | |
Cryptococcal prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Stop all | |
ART Adherence | |
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 | 160582 Reason for poor treatment adherence |
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 | |
Reason for referral (text) | |
Follow-up | |
Next Appointment Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Date medication refill is due ␣␣-␣␣-␣␣␣␣ 📆 | |
General Encounter Notes | |
General Note | |
Conditions List  | conditions-form-workspace |
OBGYN History | |
Current menstruation status 🔘 Amenorrhea 🔘 Currently pregnant 🔘 Menstruating | 082ddc79-e355-4344-a4f8-ee458c15e3ef |
LMP ␣␣-␣␣-␣␣␣␣ 📆 | 166079AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Intend to conceive in the next three months? 🔘 Yes 🔘 No 🔘 Unknown | 9109b9f3-8176-4d2f-b47d-82630dcc02ce |
Breastfeeding 🔘 Yes 🔘 No 🔘 Unknown | 5632AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Family planning method 🔘 Patient not using family planning 🔘 Currently using birth control 🔘 Requests family planning information | 160653AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
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 | 374AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Reason not on family planning 🔽 Currently not sexually active 🔽 Patient thinks she can't get pregnant 🔽 Patient wishes to get pregnant | 160575AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
EDD ␣␣-␣␣-␣␣␣␣ 📆 | 5596AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Gestational age (weeks) | 1438AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Antenatal profile done 🔘 Yes 🔘 No | 975f11e5-7471-4e57-bba7-d3ee358ef7ea |
Screened for cervical cancer during this visit 🔘 Cervical cancer screening not performed 🔘 Cervical cancer screening performed | 975f11e5-7471-4e57-bba7-d3ee358ef7ea |
Date last screened for cervical cancer ␣␣-␣␣-␣␣␣␣ 📆 | 165429AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
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) | 53ff5cd0-0f37-4190-87b1-9eb439a15e94 |
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 | 3a8bb4b4-7496-415d-a327-57ae3711d4eb |
Tuberculosis | |
Currently on treatment for tuberculosis 🔘 Yes 🔘 No 🔘 Unknown | 159798AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Currently on tuberculosis prophylaxis treatment (TPT) 🔘 Yes 🔘 No 🔘 Unknown | 166449AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Previously completed Tuberculosis preventive treatment 🔘 Yes 🔘 No 🔘 Unknown | 166463AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Evaluated for tuberculosis prophylaxis 🔘 Not applicable 🔘 Yes 🔘 No | 162275AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Tuberculosis prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Stop all | 1265AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
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 | 90c9e554-b959-48e6-90d5-8d595a074c86 |
Date tuberculosis prophylaxis started ␣␣-␣␣-␣␣␣␣ 📆 | 162320AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Tuberculosis Preventive Treatment adherence 🔘 Good 🔘 Poor 🔘 Fair 🔘 Unknown | 161653AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Date tuberculosis prophylaxis ended ␣␣-␣␣-␣␣␣␣ 📆 | 163284AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Reason tuberculosis prophylaxis stopped 🔘 Completed 🔘 Toxicity, drug 🔘 Tuberculosis 🔘 Other non-coded | 1266AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Tuberculosis treatment plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Change regimen 🔘 Dosing Change 🔘 Stop all | 1268AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Tuberculosis drug treatment start date ␣␣-␣␣-␣␣␣␣ 📆 | 1113AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Tuberculosis treatment end date ␣␣-␣␣-␣␣␣␣ 📆 | 159431AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Notes __________________________________ | 163323AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Physical/Systemic Exam | |
Lympadenopathy ☑️ Submandibular ☑️ Cervical ☑️ Supraclavicular ☑️ Axillary ☑️ Inguinal | 1121AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Cardiovascular Systems review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | 3909220e-0d0e-4547-a54e-fecd619cd861 |
Cardiovascular examination finding (Text) __________________________________ | 163046AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Gastrointestinal System review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | 3fc7236b-2b72-4a52-8286-881ea2c8dbc7 |
Abdominal examination finding (Text) __________________________________ | 160947AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Central nervous system review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | 14d61422-5323-4706-9152-781ce59c90de |
CNS examination finding (text) __________________________________ | 163109AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Screened for STIs in current visit 🔘 Yes 🔘 No 🔘 Unknown | 161558AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
STI screening findings 🔘 Genital Sore 🔘 Lower abdominal pain 🔘 Scrotal Mass 🔘 Urethral Discharge 🔘 Vaginal discharge 🔘 Normal | 118990AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Management | |
New/Active opportunistic infection 🔘 None 🔘 Opportunistic Infectious Present 🔘 Unknown | c52ecf45-bd6c-43ed-861b-9a2714878729 |
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 | 6bdf2636-7da1-4691-afcc-5eede094138f |
Fluconazole start date ␣␣-␣␣-␣␣␣␣ 📆 | 5ac4300a-5e19-45c8-8692-31a57d6d5b8c |
Fluconazole stop date ␣␣-␣␣-␣␣␣␣ 📆 | c2d57bcb-02f2-457d-af05-8d759a1457a7 |
Labs and Drugs Orders | workspace-launcher |
ARV dispensing quantity (in days) __________________________________ | 3a0709e9-d7a8-44b9-9512-111db5ce3989 |
Patient referred for other services 🔘 Yes 🔘 No | 1648AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Referral comments __________________________________ | 164359AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Attending clinician's name __________________________________ | 1473AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
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