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HAS-Haiti TB Registry Form
<htmlform> <macros> lightgrey=#e0e0e0 lightblue=#95ADCA darkblue=#4444ff </macros> <div style="background-color: $lightblue" align="center"><b>TB REJIS</b></div> <br></br> <center>Encounter Location<encounterLocation order="15,1,2,4,5,8,9"/>Encounter Date <encounterDate default="today" /></center> <br/> <table border="1" cellspacing="0" cellpadding="1" align="center" width="50%"> <tr> <td colspan="2" bgcolor="#95ADCA"><b><center>TB SPECIFIC DATA</center></b></td> </tr> <tr> <td colspan="2">Accompagnateur<obs conceptId="1603" /> Add relationship in OpenMRS <enrollInProgram programId="2"/> </td> </tr> <tr> <td colspan="2" bgcolor="whitesmoke"><obs conceptId="1004" style="checkbox" />Crachats <br/> <obs conceptId="2032" style="checkbox" /> Clinic<br/><obs conceptId="1860" style="checkbox" /> X-Ray</td> </tr> <tr> <td colspan="2">TB Type<obs conceptId="2058" /><br/>TB Patient Type<obs conceptId="1623" /></td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td width="40%">Pre-Traitement Bacilloscopie</td><td><obs conceptId="2048" answers="A+B+C+,A+B+C-,A+B-C-,A-B-C-,A-B-C+,A-B+C+,A+B-C+,A-B+C-" answerLabels="A+B+C+,A+B+C-,A+B-C-,A-B-C-,A-B-C+,A-B+C+,A+B-C+,A-B+C-" style="dropdown" showDate="true" />Date </td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td> Fin du: 2e mois Bacilloscopie</td><td><obs conceptId="2050" answers="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" answerLabels="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" style="dropdown" showDate="true" />Date </td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>Fin du:3e mois Bacilloscopie</td><td><obs conceptId="2052" answers="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" answerLabels="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" style="dropdown" showDate="true" />Date </td> </tr> <tr><td colspan="3" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>Fin du: 5e mois Bacilloscopie</td><td><obs conceptId="2054" answers="-\--,--+" answerLabels="+-+\--,+" style="dropdown" showDate="true" />Date </td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>Fin du Traitement Bacilloscopie</td><td><obs conceptId="2055" answers="-\--,--+" answerLabels="+-+\--,+" style="dropdown" showDate="true" />Date </td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>Résultat Test Hiv</td><td><obs conceptId="1040" showDate="true" size="15"/>Date </td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>CD4 Count</td><td><obs conceptId="5497" showDate="true" />Date </td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>Date début Traitement ARV</td><td><obs conceptId="101" /></td> </tr> <tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>Resultat de Traitement TB</td><td><obs conceptId="1607" showDate="true" />Date </td> </tr> <tr><td colspan="3" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr> <tr> <td>Remarque</td><td><obs conceptId="1602" /></td> </tr> </table> <center><encounterProvider role="Provider" /><submit /></center> </htmlform>
HAS-Haiti Surgery Form
<htmlform> <macros> lightgrey=#e0e0e0 lightblue=#2ea991 green=#2ea991 white=#ffffff </macros> <div style="background-color: $green;color:$white"><b><center>Surgery Form</center></b></div> <br/> <table border="1" width="80%" cellspacing="0" align="center" bgcolor="whitesmoke"> <tr> <td>Operation Date <encounterDate /></td><td>Operation Time <obs conceptId="6164" allowFutureDates="true"/></td><td >Emergency Type <obs conceptId="6162" /></td> </tr> <tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>ANESTHESIA</B></td></tr> <tr> <td>Anesthesia Type<obs conceptId="6142" /></td><td width="40%">Start time <obs conceptId="6143" allowFutureDates="true"/> / End Time <obs conceptId="6144" allowFutureDates="true"/> </td><td >Anesthesiologist <obs conceptId="6165" answers="Nonine Vernéus,Yves-Rose Pierre Louis,Espinel Solius" /></td> </tr> <tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>DIAGNOSIS</B></td></tr> <tr ><td colspan="3"><obs conceptId="6178" answerClasses="Diagnosis" style="autocomplete" size="80" /></td></tr> <tr ><td colspan="3"><obs conceptId="6178" answerClasses="Diagnosis" style="autocomplete" size="80" /></td></tr> <tr ><td colspan="3"><obs conceptId="6178" answerClasses="Diagnosis" style="autocomplete" size="80" /></td></tr> <tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>PROCEDURE</B></td></tr> <tr> <td colspan="3"><obs conceptId="6179" answerClasses="Procedure" style="autocomplete" /></td></tr> <tr> <td colspan="3"><obs conceptId="6179" answerClasses="Procedure" style="autocomplete" /></td></tr> <tr> <td colspan="3"><obs conceptId="6179" answerClasses="Procedure" style="autocomplete" /></td></tr> <tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>NURSES</B></td></tr> <tr><td><b>Scrub</b></td><td><b>Circulating</b></td><td><b>Comments</b></td></tr> <tr> <td>1. <obs conceptId="6167" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Rosette Vilna,Wastaline Charles" /> <br> 2. <obs conceptId="6167" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Rosette Vilna,Wastaline Charles" /> </br> <br> 3. <obs conceptId="6167" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Rosette Vilna,Wastaline Charles" /> </br> </td> <td>1. <obs conceptId="6168" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Elioné Billion,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Mireille Jean,Nacha Betty Benoit,Rosette Vilna,Wastaline Charles,Wilner Alcene" /> <br> 2. <obs conceptId="6168" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Elioné Billion,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Mireille Jean,Nacha Betty Benoit,Rosette Vilna,Wastaline Charles,Wilner Alcene" /> </br> <br> 3. <obs conceptId="6168" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Elioné Billion,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Mireille Jean,Nacha Betty Benoit,Rosette Vilna,Wastaline Charles,Wilner Alcene" /> </br></td> <td> <obs conceptId="1602" style="textarea" /></td> </tr> <tr> <td colspan="3" align="center"> Lieu <encounterLocation default="15" order="15"/> Surgeon Name <encounterProvider role="Surgeon"/> <submit /> </td> </tr> </table> </htmlform>
HAS-Haiti Family Registry Form
<htmlform> <macros> lightgrey=#e0e0e0 lightblue=#95ADCA darkblue=#4444ff </macros> <div style="background-color: $lightblue" align="center"><b>REJIS FANMI</b></div> <br></br> <center><encounterLocation order="1,2,4,5,8,9"/><encounterDate default="today" /></center> <table bgcolor="#f9f9f9" border="1" cellspacing="6" cellpadding="4" width="75%" align="center"> <tr> <td align="center" > <table border="1" cellspacing="0" cellpadding="3" width="95%"> <tr> <td>Pwa (Kg) / Dat yo pran pwa a </td><td><obs conceptId="5089" showDate="true" /></td><td style="font-weight:bold" align="center">Koz Vizit la / Dat vizit </td> </tr> <tr> <td>Etat pwa a</td><td><obs conceptId="2974" /></td><td><obs conceptId="2959" showDate="true" /></td> </tr> <tr > <td colspan="2"></td><td><obs conceptId="2959" showDate="true" /></td> </tr> <tr> <td colspan="2"></td><td><obs conceptId="2959" showDate="true" /></td> </tr> <tr> <td colspan="2"></td><td><obs conceptId="2959" showDate="true" /></td> </tr> </table> </td> </tr> <tr> <td align="center" ><table border="1" cellspacing="0" cellpadding="3" width="95%"> <tr> <td align="center" style="font-weight:bold" colspan="4" bgcolor="#95ADCA"> VAKSINASYON</td> </tr> <tr style="font-weight:bold"> <td >Vaksen</td><td>Dat vaksinasyon</td><td>fabrikan </td><td>nimewo estòk</td> </tr> <obsgroup groupingConceptId="3025"> <tr> <td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td> </tr> </obsgroup> <obsgroup groupingConceptId="3025"> <tr> <td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td> </tr> </obsgroup> <obsgroup groupingConceptId="3025"> <tr> <td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td> </tr> </obsgroup> <obsgroup groupingConceptId="3025"> <tr> <td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td> </tr> </obsgroup> </table></td> </tr> <tr> <td align="center" ><table border="1" cellspacing="0" cellpadding="3" width="95%"> <tr > <td style="font-weight:bold">Vitamin A</td><td style="font-weight:bold">Fè</td><td style="font-weight:bold">Albendazol</td><td>Gwosès</td><td><obs conceptId="5272" /></td> </tr> <tr> <td><obs conceptId="2231" /></td> <td><obs conceptId="2971" /></td> <td><obs conceptId="941" /></td><td>Kantite semèn gwosès</td><td><obs conceptId="1279" /></td> </tr> <tr> <td><obs conceptId="2231" /></td> <td><obs conceptId="2971" /></td> <td><obs conceptId="941" /></td><td>swen avan nesans</td><td><obs conceptId="2992" /></td> </tr> <tr> <td colspan="3"> </td><td>Swen apre nesans</td><td><obs conceptId="2993" /></td> </tr> <tr> <td>metod planifikasyon familyal</td><td><obs conceptId="374" /></td><td></td><td>Alètman</td><td><obs conceptId="5632" /></td> </tr> </table></td> </tr> </table> <center><encounterProvider role="Provider" /><submit /></center> </htmlform>
HAS-Haiti Lab Form
<htmlform> <macros> lightgrey=#e0e0e0 lightblue=#95ADCA darkblue=#4444ff </macros> <div style="background-color: $lightblue"><b><center>LABORATORY FORM ENTRY</center></b></div> <br></br> <center>Encounter Date <encounterDate default="today" /> Location <encounterLocation default="15" order="15" /> <obs conceptId="2933" labelText="Payment" /> <obs conceptId="1827" labelText="Ward" /></center> <table border="1" width="95%" cellspacing="6" cellpadding="6" bgcolor="whitesmoke" align="center"> <tr> <td> <table border="1" cellspacing="0" align="center" width="95%"> <tr> <td colspan="10" align="center" bgcolor="#95ADCA"><b>CHIMIE</b></td> </tr> <tr style="font-weight:bold"> <td>Test name</td><td>Result</td><td>Ref-m</td><td>Ref-f</td><td>Test name</td><td>Result</td><td>Ref-m</td><td>Ref-f</td> </tr> <tr style="font-weight:bold"> <td colspan="4">Tests Hepatiques</td><td colspan="4"> Tests lipidiques</td> </tr> <tr> <td>Bilirubin Total</td><td><obs conceptId="2840"/>mg/dl</td><td>0.2-1.3</td><td>0.2-1.3</td><td>Cholesterol</td><td><obs conceptId="2890"/>mg/dl</td><td>0.8-1.5</td><td>0.7-1.2</td> </tr> <tr> <td>Bilirubin Neonatal</td><td><obs conceptId="1371" />mg/dl</td><td>1.0-10.5</td><td>1.0-10.5</td><td >Triglycerides</td><td><obs conceptId="1009" />mg/dl</td><td> inf. à150</td><td>inf. à 150</td> </tr> <tr> <td>ALT/GPT</td><td><obs conceptId="2842" />U/l</td><td>21-72</td><td>12-43</td><td>HDL Cholesterol</td><td><obs conceptId="2848" />mg/dl</td><td>inf. à 40</td><td>inf. à 40</td> </tr> <tr> <td>AST/GOT</td><td><obs conceptId="2841" />U/l</td><td>17-59</td><td>14-36</td><td colspan="4">Pancreas</td> </tr> <tr> <td>GGT</td><td><obs conceptId="1370" />U/l</td><td>15-73</td><td>9-52</td><td>Amylase</td><td><obs conceptId="1299" />U/l</td><td>30-110</td><td>30-110</td> </tr> <tr> <td>ALK Phosphatase</td><td><obs conceptId="785" />U/l</td><td>38-126</td><td>38-126</td><td>Lipase</td><td><obs conceptId="1013" />U/l</td><td>23-300</td><td>23-300</td> </tr> <tr style="font-weight:bold"> <td colspan="4">Function Renal</td><td colspan="4">Proteine</td> </tr> <tr> <td>Urea Nitrogen/BUN</td><td><obs conceptId="2889" />mg/dl</td><td>9-20</td><td>7-17</td><td>Albumin</td><td><obs conceptId="2928" />g/dl</td><td>35-50</td><td>35-50</td> </tr> <tr> <td>Creatinine</td><td><obs conceptId="2888" />mg/dl</td><td>0.8-1.5</td><td>0.7-1.2</td><td>Total Protein</td><td><obs conceptId="717" />g/dl</td><td>63-82</td><td>63-82</td> </tr> <tr> <td>Uric Acid</td><td><obs conceptId="1373" />mg/dl</td><td>3.5-8.5</td><td>2.5-6.2</td><td>TP/Albumin Quotient</td><td><obs conceptId="3009" /></td><td></td><td></td> </tr> <tr style="font-weight:bold"> <td colspan="4" >Electrolyte /Oligo-Element</td><td colspan="4">Cardio Risk</td> </tr> <tr> <td>Sodium</td><td><obs conceptId="2843" />mmol</td><td>137-145</td><td>137-145</td><td>CK</td><td><obs conceptId="1011" />U/l</td><td>55-175</td><td>30-135</td> </tr> <tr> <td>Potassium</td><td><obs conceptId="2844" />mmol/l</td><td>3.5-5.1</td><td>3.5-5.1</td><td>CKMB</td><td><obs conceptId="1378" />U/l</td><td></td><td></td> </tr> <tr> <td>Cloride</td><td><obs conceptId="2845" />mmol/l</td><td>98-107</td><td>98-107</td><td colspan="5"></td> </tr> <tr> <td>Calcium</td><td><obs conceptId="1379" />mg/dl</td><td>8.4-10.2</td><td>8.4-10.2</td><td colspan="5"></td> </tr> <tr> <td>Magnesium</td><td><obs conceptId="1387" />mg/dl</td><td>1.6-2.3</td><td>1.6-2.3</td><td>Fer/fe</td><td><obs conceptId="2850" />Umol/</td><td>8.8-32.24</td><td>6.0-30.4</td> </tr> <tr> <td>Co2</td><td><obs conceptId="2846" />mmol/l</td><td>22-30</td><td>22-30</td><td>HB Glycolysé</td><td><obs conceptId="1852" />%</td><td></td><td></td> </tr> <tr> <td>Amonia</td><td><obs conceptId="2847" />Umol/l</td><td>9-30</td><td>9-30</td><td>Glucose2</td><td><obs conceptId="887" />mg/dl</td><td>70-110</td><td>70-110</td> </tr> </table></td> </tr> <tr> <td> <table border="1" cellspacing="0" align="center" width="95%"> <tr> <td colspan="8" align="center" bgcolor="#95ADCA"><b>HEMATOLOGIE</b></td> </tr> <tr> <td>Hematocrite</td><td><obs conceptId="1015" />%</td><td colspan="2" style="font-weight:bold"> Morphologie<obs conceptId="1374" style="checkbox" /></td><td colspan="2" style="font-weight:bold">Differential <obs conceptId="1026" style="checkbox" />%</td> </tr> <tr> <td>Platelets</td><td><obs conceptId="729" />x10^9/1</td><td>Anisocytocis</td><td><obs conceptId="2894" /></td><td>Neurophilis Band</td><td><obs conceptId="2910" /></td> </tr> <tr> <td>Reticulocytes</td><td><obs conceptId="1327" />%</td><td>Microcytosis</td><td><obs conceptId="2895" /></td><td>Neutrophilis Seg</td><td><obs conceptId="2911" /></td> </tr> <tr> <td>Temps de saignement</td><td><obs conceptId="1384" />sec</td><td>Anisochromasie</td><td><obs conceptId="2905" /></td><td>Eosinophils</td><td><obs conceptId="1024" /></td> </tr> <tr> <td>Temps de Coagulation</td><td><obs conceptId="2909" />sec</td><td>Polychromasie</td><td><obs conceptId="2901" /></td><td>Basophils</td><td><obs conceptId="1025" /></td> </tr> <tr> <td>PT/INR</td><td><obs conceptId="2999" />sec</td><td>Macrocytosis</td><td><obs conceptId="2896" /></td><td>Monocytes</td><td><obs conceptId="1023" /></td> </tr> <tr> <td>Vitesse sedimentaion</td><td><obs conceptId="1878" /></td><td>Spherocytes</td><td><obs conceptId="2904"/></td><td>Lymphocytes</td><td><obs conceptId="1021" /></td> </tr> <tr> <td>Sickling Test</td><td><obs conceptId="1369" /></td><td>Poikilocytose</td><td><obs conceptId="2898" /></td><td>Normoblast</td><td><obs conceptId="3010" /></td> </tr> <tr> <td>CD4</td><td><obs conceptId="5497" /></td><td>Hypochromasie</td><td><obs conceptId="2900" /></td><td>Myeloblastes</td><td><obs conceptId="1730" /></td> </tr> <tr> <td>Malaria Smear</td><td><obs conceptId="32" /></td><td>Basophils stipling </td><td><obs conceptId="2902" /></td><td>Myelocytes</td><td><obs conceptId="3028" /></td> </tr> <tr> <td>Proteine-c Reactive</td><td><obs conceptId="6232" />mg/l</td><td>Target Cells</td><td><obs conceptId="2903" /></td><td>Promyelocytes</td><td><obs conceptId="3029" /></td> </tr> <tr> <td>Hemoglobine</td><td><obs conceptId="21" />g/dl</td><td>Ovalo/Elliptocytose</td><td><obs conceptId="2897" /></td><td>Metamyelocytes</td><td><obs conceptId="3030" /></td> </tr> <tr> <td>WBC/globule blanc</td><td><obs conceptId="678" /></td><td>Megalocyte</td><td><obs conceptId="3211" /></td><td>NRBC/100 WBC</td><td><obs conceptId="2912" /></td> </tr> <tr> <td>WBC Corrected</td><td><obs conceptId="6131" /></td><td></td><td></td><td>Plasma Cell</td><td><obs conceptId="1002" /></td> </tr> <tr> <td colspan="4"></td><td>Atyp. Cells</td><td><obs conceptId="1328" /></td> </tr> </table> </td> </tr> <tr> <td> <table border="1" cellspacing="0" align="center" width="95%"> <tr> <td colspan="6" align="center" bgcolor="#95ADCA" cellspacing="2"><b>ANALYSE URINE</b></td> </tr> <tr style="font-weight:bold"> <td>MACROSCOPIC<obs conceptId="2995" style="checkbox" /></td><td>RESULTAT</td><td>MICROSCOPIC<obs conceptId="2994" style="checkbox" /></td><td>RESULTAT</td> </tr> <tr> <td>Sang</td><td><obs conceptId="3063"/></td><td>WBC</td><td><obs conceptId="2922" /></td> </tr> <tr> <td>Urobilinogen</td><td><obs conceptId="3011" />mg/dl</td><td>RBC</td><td><obs conceptId="2923" /></td> </tr> <tr> <td>Bilirubin</td><td><obs conceptId="2919" /></td><td>Epithelial cells</td><td><obs conceptId="666" /></td> </tr> <tr> <td>Protein</td><td><obs conceptId="2887" />mgdl</td><td>Bacteria</td><td><obs conceptId="724" /></td> </tr> <tr> <td>Nitrite</td><td><obs conceptId="2921" /></td><td>Mucus Threads</td><td><obs conceptId="2925" /></td> </tr> <tr> <td>Ketone</td><td><obs conceptId="2885" /></td><td>Amphorous po4/urates</td><td><obs conceptId="2924" /></td> </tr> <tr> <td>Sucre</td><td><obs conceptId="2916" />mg/dl</td><td>Cast/hyalin</td><td><obs conceptId="2926" /></td> </tr> <tr> <td>pH</td><td><obs conceptId="2917" /></td><td>Casts wachs</td><td><obs conceptId="6132" /></td> </tr> <tr> <td>Gravité specifique</td><td><obs conceptId="2920" /></td><td>Crystals </td><td><obs conceptId="2927" /></td> </tr> <tr> <td>Urine Pregnancy Test</td><td><obs conceptId="45" /></td><td>Proteinurie</td><td><obs conceptId="1383" /></td> </tr> </table> </td> </tr> <tr> <td> <table border="1" width="95%" cellspacing="0" align="center"> <tr> <td colspan="8" align="center" bgcolor="#95ADCA"><b>EXAMEN DE SEL</b></td> </tr> <tr style="font-weight:bold"> <td colspan="4">Ova and Parasites<obs conceptId="2996" style="checkbox" /></td><td colspan="2">Stool Guaiac Test<obs conceptId="1372" style="checkbox"/></td> </tr> <tr> <td>E. Coli</td><td><obs conceptId="709" /></td><td>Ascaris Ova</td><td><obs conceptId="716" /></td><td>Blood</td><td><obs conceptId="2918" /></td> </tr> <tr> <td></td><td></td><td>Hookworm</td><td><obs conceptId="2934" /></td><td>Fat</td><td><obs conceptId="2938" /></td> </tr> <tr> <td>E. nana</td><td><obs conceptId="2940" /></td><td>Trichirus</td><td><obs conceptId="2935" /></td><td>Mucus</td><td><obs conceptId="2939" /></td> </tr> <tr> <td>I Butschili</td><td><obs conceptId="2941" /></td><td>Taenia Ova</td><td><obs conceptId="2936" /></td><td></td><td></td> </tr> <tr> <td>Giardia</td><td><obs conceptId="1797" /></td><td>Hymenolepsis</td><td><obs conceptId="2937" /></td><td></td><td></td> </tr> <tr> <td>Trichomonas</td><td><obs conceptId="684" /></td><td></td><td></td><td></td><td></td> </tr> </table> </td> </tr> <tr> <td> <table align="center" cellspacing="0" border="1" width="50%"> <tr> <td colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> SEROLOGIE BANQUE DE SANG </td> </tr> <tr> <td>Groupe Sanguin </td><td><obs conceptId="300" /></td><td>Cross-Match</td><td><obs conceptId="3033" /></td> </tr> </table> </td> </tr> <tr> <td> <table align="center" cellspacing="0" border="1" width="95%"> <tr> <td colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> SEROLOGIE </td> </tr> <tr><td>Hepatite B</td><td><obs conceptId="1844" /></td><td>Vidal Test</td><td><obs conceptId="306" /></td></tr> <tr><td>ASO</td><td><obs conceptId="1874" /></td><td>Cryptococose</td><td><obs conceptId="1219" /></td></tr> <tr> <td colspan="2">Syphilis <obs conceptId="223" style="no_yes" /></td><td>HIV <obs conceptId="1040" /></td><td></td> </tr> </table> </td> </tr> <tr> <td> <table align="center" cellspacing="0" border="1" width="95%"> <tr> <td colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> LIQUIDE CORPORELLE </td> </tr> <tr> <td >Liquide cerebrospinale <obs conceptId="1377" style="checkbox" /></td><td>Pleural<obs conceptId="2011" style="checkbox" /></td><td>Ascitique <obs conceptId="1917" style="checkbox" /></td><td></td> </tr> <tr> <td>Cell count : Globule Blanc</td><td><obs conceptId="3060" />mm3</td><td>Protein</td><td><obs conceptId="3016" />mg/dl</td> </tr> <tr> <td>Globue rouge</td><td><obs conceptId="1879" />mm3</td><td>Sucre</td><td><obs conceptId="3062" />mg/dl</td> </tr> <tr> <td>Differentiel:Lymphs</td><td><obs conceptId="3061" />%</td><td></td><td></td> </tr> <tr> <td>Polys</td><td><obs conceptId="1022" />%</td><td>Other</td><td><obs conceptId="1939" /></td> </tr> <tr><td colspan="2">Cytologie<obs conceptId="3000" style="checkbox" /></td><td colspan="2">Chimie <obs conceptId="3001" style="checkbox" /></td></tr> </table> </td> </tr> <tr> <td> <table align="center" cellspacing="0" border="1" width="95%"> <tr> <td colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> BACTERIOLOGIE / BACILLOSCOPIE </td> </tr> <tr> <td colspan="2">TB crachat <obs conceptId="6130" /></td><td>Culture</td><td><obs conceptId="2870" /></td> </tr> <tr> <td colspan="4">Gram Stain <obs conceptId="1382" size="100"/></td> </tr> </table> </td> </tr> <tr><td align="center">Remarque <obs conceptId="1602" size="150" /></td></tr> </table> <center><encounterProvider role="Hospital Provider"/> <submit /></center> </htmlform>
HAS-Haiti Dispensary Form
<htmlform> <macros> lightgrey=#e0e0e0 lightblue=#95ADCA darkblue=#4444ff </macros> <div style="background-color: $lightblue" align="center"><b>FOM KONSILTASYON DISPANSE </b></div><BR/> <center>Location <encounterLocation order="1,2,4,5,8,9"/> Date <encounterDate /></center> <table bgcolor="#f9f9f9" border="1" width="80%" cellspacing="4" cellpadding="6" align="center"> <tr> <td> <table border="1" cellspacing="0" width="95%" align="center"> <tr> <td>KOB <obs conceptId="1719" />goud</td> <td>TMP <obs conceptId="5088" /></td> <td>TA <obs conceptId="5085" /> / <obs conceptId="5086" /></td> <td>PWA <obs conceptId="5089" />kg</td> </tr> </table> </td> </tr> <tr> <td> <table border="1" cellspacing="0" width="95%" align="center"> <tr><td colspan="3" bgcolor="#95ADCA" align="center"><b>DYAGNOSTIK</b></td></tr> <tr> <td>TIP VIZIT</td> <td>TIP DYAGNOSTIK</td> <td>KOD DYAGNOSTIK</td> </tr> <repeat> <template> <includeIf velocityTest="(($patient.gender == 'F') || ($patient.gender)) && ($patient.gender != 'M')"> <obsgroup groupingConceptId="2629"> <tr> <td><obs conceptId="3100" /></td> <td><obs conceptId="3104" /></td> <td><obs conceptId="2879" answerConceptIds="3125,114,3149,1799,3159,3165,3178,3185,10,3126,43,3137,3138,1899,3139,3140,3141,891,1903,3142,3143,3144,3145,3146,117,3147,3148,1905,5334,3150,1910,212,16,1797,3151,3152,3153,3154,1801,29,1913,3155,3156,151,3157,3158,140,1970,3160,3161,892,3162,63,1965,3163,1998,3164,134,128,166,1981,1798,3166,3167,3168,6103,3170,3179,1927,1920,3182,3183,3177,123,141,3176,3184,3186,3,3187,3188,3189,1796,3190,903,3191,3192,3175,1949,1945,1942,1800,3171,3172,3173,3174,3127,3128,2014,5995,3129,3130,127,3131,3132,3133,3134,3136" answerLabels="1-INFECTIVE OTITIS EXTERNA UNSPECIFIED (3125) ,2-UNSPECIFIED OTITIS MEDIA (114) ,3-ACUTE TONSILLITIS (3149) ,4-DIPHTHERIA UNSPECIFIED (1799) ,5-ACUTE NASOPHARYNGITIS (COMMON COLD) (3159) ,6-ACUTE LARYNGITIS (3165) ,7-ACUTE SINUSITIS (3178) ,8-OTHER DISEASES OF UPPER RESPIRATORY TRACT (3185) ,9-ACUTE BRONCHITIS (10) ,10-UNSPECIFIED CHRONIC BRONCHITIS (3126) ,11-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED (43) ,12-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED GRAVE PNEUMONIA (3137) ,13-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED TRES GRAVE (3138) ,14-ASTHMA LEGER (1899) ,15-ASTHMA CRISE SEVERE (3139) ,16-UNSPECIFIED PULMONARY TUBERCULOSIS SUSPICION (3140) ,17-UNSPECIFIED PULMONARY TUBERCULOSIS EN TRAITEMENT (3141) ,18-WHOOPING COUGH DUE TO BORDETELLA PERTUSSIS (B. PERTUSSIS) (891) ,19-UNSPECIFIED PLEURAL EFFUSION (1903) ,20-OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED (3142) ,21-ACUTE PERICARDITIS UNSPECIFIED (3143) ,23-HEART FAILURE UNSPECIFIED (3144) ,24-PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) (3145) ,25-VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED (3146) ,26-OTHER AND UNSPECIFIED CONJUNCTIVITIS (117) ,27-CONJUNCTIVAL XEROSIS (3147) ,28-UNSPECIFIED DISORDER OF EYE AND ADNEXA (3148) ,29-ESOPHAGITIS (1905) ,30-CANDIDIASIS OF MOUTH (5334) ,31-PERIAPICAL ABSCESS WITHOUT SINUS (3150) ,32-UNSPECIFIED GASTRITIS AND GASTRODUODENITIS DYSPEPSIA PEPTICULCERS ETC. (1910) ,33-GASTRIC ULCER (212) ,34-DIARRHEA OF PRESUMED INFECTIOUS ORIGIN DIARRHEAL DISEASES (16) ,35-GIARDIASIS (1797) ,36-SHIGELLOSIS UNSPECIFIED (3151) ,37-AMEBIASIS UNSPECIFIED (3152) ,38-VOLUME DEPLETION DISORDER DEGREE A (3153) ,39-VOLUME DEPLETION DISORDER DEGREE B (3154) ,40-VOLUME DEPLETION DISORDER DEGREE C (1801) ,41-HEPATITIS UNSPECIFIED (29) ,42-UNSPECIFIED PERITONITIS (1913) ,43-UNSPECIFIED HEMORRHOIDS WITHOUT MENTION OF COMPLICATION (3155) ,44-HERNIA OF OTHER SPECIFIED SITES WITHOUT MENTION OF OBSTRUCTION ORGANGRENE (3156) ,45-ABDOMINAL PAIN (151) ,46-INTESTINAL PARASITISM UNSPECIFIED (3157) ,47-OTHER DISORDERS OF INTESTINE (3158) ,48-SCABIES (140) ,49-PRURIGO (1970) ,50-UNSPECIFIED URTICARIA (3160) ,51-TOXOCARIASIS (3161) ,52-VARICELLA WITHOUT MENTION OF COMPLICATION (892) ,53-OTHER AND UNSPECIFIED MYCOSES (3162) ,54-MEASLES WITHOUT MENTION OF COMPLICATION MEASLES (63) ,55-IMPETIGO (1965) ,56-PITYRIASIS VERSICOLOR (3163) ,57-ANTHRAX UNSPECIFIED (1998) ,58-ULCER OF LOWER LIMBS EXCEPT DECUBITUS ULCER (3164) ,59-CELLULITIS AND ABSCESS OF UNSPECIFIED SITES (134) ,60-OPEN WOUND(S) (MULTIPLE) OF UNSPECIFIED SITE(S) WITHOUT MENTION OF COMPLICATION (128) ,61-DOG BITE (166) ,62-FRACTURE OF UNSPECIFIED BONE CLOSED (1981) ,63-CONTUSION OF UNSPECIFIED SITE (1798) ,64-UNSPECIFIED SITE OF SPRAIN AND STRAIN (3166) ,65-PYOGENIC ARTHRITIS (3167) ,67-UNSPECIFIED ARTHROPATHY (3168) ,68-OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED (6103) ,69-SCIATICA (3170) ,70-LUMBAGO (3179) ,71-NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY (1927) ,72-CYSTITIS UNSPECIFIED (1920) ,73-URINARY CALCULUS UNSPECIFIED (3182) ,74-ACUTE PYELONEPHRITIS (3183) ,75-RETENTION OF URINE (3177) ,76-UNSPECIFIED MALARIA (123) ,77-TYPHOID FEVER TYPHOID FEVER (141) ,78-RELAPSING FEVER (3176) ,79-HB-S DISEASE WITH MENTION OF CRISIS ANEMIA (3184) ,80-SICKLE-CELL ANEMIA (3186) ,81-ANEMIA UNSPECIFIED (3) ,82-MALNUTRITION OF MILD DEGREE MALNUTRITION (3187) ,83-MALNUTRITION OF MODERATE DEGREE MALNUTRITION (3188) ,84-OTHER SEVERE PROTEIN-CALORIE MALNUTRITION MALNUTRITION (3189) ,85-KWASHIORKOR MALNUTRITION (1796) ,86-ACQUIRED IMMUNODEFICIENCY SYNDROME UNSPECIFIED SUSPICION SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3190) ,88-ESSENTIAL HYPERTENSION (903) ,89-MILD OR UNSPECIFIED PRE-ECLAMPSIA COMPLICATION OF PREGNANCY DELIVERY AND PUERPERIUM (3191) ,90-ECLAMPSIA COMPLICATING PREGNANCY CHILDBIRTH OR THE PUERPERIUM COMPLICATION OF PREGNANCY DELIVERY AND PUERPERIUM (3192) ,91-OTHERS (CANCER HYPERTHYROID ETC.) (3175) ,92-MENINGITIS UNSPECIFIED (1949) ,93-EPILEPSY UNSPECIFIED (1945) ,94-HYSTERIA UNSPECIFIED (1942) ,95-COMA (1800) ,96-CONCUSSION UNSPECIFIED (3171) ,97-PREGNANCY EXAMINATION OR TEST PREGNANCY UNCONFIRMED PRENATAL I (3172) ,98-PREGNANCY EXAMINATION OR TEST PREGNANCY UNCONFIRMED PRENATAL II (3173) ,99-PREGNANCY EXAMINATION OR TEST PREGNANCY UNCONFIRMED PRENATAL III (3174) ,100-LATENT SYPHILIS UNSPECIFIED SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3127) ,101-UNSPECIFIED ABORTION COMPLICATION OF PREGNANCY DELIVERY AND PUERPERIUM (3128) ,102-CHANCROID PLUS CHANCRE (2014) ,103-URETHRAL DISCHARGE (5995) ,104-OTHER ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITHOUT MENTION OF ABSCESS (3129) ,105-OTHER VENEREAL DISEASES SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3130) ,106-DYSMENORRHEA (127) ,108-UNSPECIFIED DISORDERS OF MENSTRUSTION (3131) ,109-HYDROCELE UNSPECIFIED (3132) ,110-UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS (3133) ,111-UNATTENDED DEATH (3134) ,113-CHILD DELIVERY (3136) "/></td> </tr></obsgroup> </includeIf> <includeIf velocityTest="$patient.gender == 'M' "> <obsgroup groupingConceptId="2629"> <tr> <td><obs conceptId="3100" /></td> <td><obs conceptId="3104" /></td> <td><obs conceptId="2879" answerConceptIds="3125,114,3149,1799,3159,3165,3178,3185,10,3126,43,3137,3138,1899,3139,3140,3141,891,1903,3142,3143,3144,3145,3146,117,3147,3148,1905,5334,3150,1910,212,16,1797,3151,3152,3153,3154,1801,29,1913,3155,3156,151,3157,3158,140,1970,3160,3161,892,3162,63,1965,3163,1998,3164,134,128,166,1981,1798,3166,3167,3168,6103,3170,3179,1927,1920,3182,3183,3177,123,141,3176,3184,3186,3,3187,3188,3189,1796,3190,903,3175,1949,1945,1942,1800,3171,3127,2014,5995,3129,3130,3132,3134" answerLabels="1-INFECTIVE OTITIS EXTERNA UNSPECIFIED (3125) ,2-UNSPECIFIED OTITIS MEDIA (114) ,3-ACUTE TONSILLITIS (3149) ,4-DIPHTHERIA UNSPECIFIED (1799) ,5-ACUTE NASOPHARYNGITIS (COMMON COLD) (3159) ,6-ACUTE LARYNGITIS (3165) ,7-ACUTE SINUSITIS (3178) ,8-OTHER DISEASES OF UPPER RESPIRATORY TRACT (3185) ,9-ACUTE BRONCHITIS (10) ,10-UNSPECIFIED CHRONIC BRONCHITIS (3126) ,11-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED (43) ,12-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED GRAVE PNEUMONIA (3137) ,13-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED TRES GRAVE (3138) ,14-ASTHMA LEGER (1899) ,15-ASTHMA CRISE SEVERE (3139) ,16-UNSPECIFIED PULMONARY TUBERCULOSIS SUSPICION (3140) ,17-UNSPECIFIED PULMONARY TUBERCULOSIS EN TRAITEMENT (3141) ,18-WHOOPING COUGH DUE TO BORDETELLA PERTUSSIS (B. PERTUSSIS) (891) ,19-UNSPECIFIED PLEURAL EFFUSION (1903) ,20-OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED (3142) ,21-ACUTE PERICARDITIS UNSPECIFIED (3143) ,23-HEART FAILURE UNSPECIFIED (3144) ,24-PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) (3145) ,25-VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED (3146) ,26-OTHER AND UNSPECIFIED CONJUNCTIVITIS (117) ,27-CONJUNCTIVAL XEROSIS (3147) ,28-UNSPECIFIED DISORDER OF EYE AND ADNEXA (3148) ,29-ESOPHAGITIS (1905) ,30-CANDIDIASIS OF MOUTH (5334) ,31-PERIAPICAL ABSCESS WITHOUT SINUS (3150) ,32-UNSPECIFIED GASTRITIS AND GASTRODUODENITIS DYSPEPSIA PEPTICULCERS ETC. (1910) ,33-GASTRIC ULCER (212) ,34-DIARRHEA OF PRESUMED INFECTIOUS ORIGIN DIARRHEAL DISEASES (16) ,35-GIARDIASIS (1797) ,36-SHIGELLOSIS UNSPECIFIED (3151) ,37-AMEBIASIS UNSPECIFIED (3152) ,38-VOLUME DEPLETION DISORDER DEGREE A (3153) ,39-VOLUME DEPLETION DISORDER DEGREE B (3154) ,40-VOLUME DEPLETION DISORDER DEGREE C (1801) ,41-HEPATITIS UNSPECIFIED (29) ,42-UNSPECIFIED PERITONITIS (1913) ,43-UNSPECIFIED HEMORRHOIDS WITHOUT MENTION OF COMPLICATION (3155) ,44-HERNIA OF OTHER SPECIFIED SITES WITHOUT MENTION OF OBSTRUCTION ORGANGRENE (3156) ,45-ABDOMINAL PAIN (151) ,46-INTESTINAL PARASITISM UNSPECIFIED (3157) ,47-OTHER DISORDERS OF INTESTINE (3158) ,48-SCABIES (140) ,49-PRURIGO (1970) ,50-UNSPECIFIED URTICARIA (3160) ,51-TOXOCARIASIS (3161) ,52-VARICELLA WITHOUT MENTION OF COMPLICATION (892) ,53-OTHER AND UNSPECIFIED MYCOSES (3162) ,54-MEASLES WITHOUT MENTION OF COMPLICATION MEASLES (63) ,55-IMPETIGO (1965) ,56-PITYRIASIS VERSICOLOR (3163) ,57-ANTHRAX UNSPECIFIED (1998) ,58-ULCER OF LOWER LIMBS EXCEPT DECUBITUS ULCER (3164) ,59-CELLULITIS AND ABSCESS OF UNSPECIFIED SITES (134) ,60-OPEN WOUND(S) (MULTIPLE) OF UNSPECIFIED SITE(S) WITHOUT MENTION OF COMPLICATION (128) ,61-DOG BITE (166) ,62-FRACTURE OF UNSPECIFIED BONE CLOSED (1981) ,63-CONTUSION OF UNSPECIFIED SITE (1798) ,64-UNSPECIFIED SITE OF SPRAIN AND STRAIN (3166) ,65-PYOGENIC ARTHRITIS (3167) ,67-UNSPECIFIED ARTHROPATHY (3168) ,68-OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED (6103) ,69-SCIATICA (3170) ,70-LUMBAGO (3179) ,71-NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY (1927) ,72-CYSTITIS UNSPECIFIED (1920) ,73-URINARY CALCULUS UNSPECIFIED (3182) ,74-ACUTE PYELONEPHRITIS (3183) ,75-RETENTION OF URINE (3177) ,76-UNSPECIFIED MALARIA (123) ,77-TYPHOID FEVER TYPHOID FEVER (141) ,78-RELAPSING FEVER (3176) ,79-HB-S DISEASE WITH MENTION OF CRISIS ANEMIA (3184) ,80-SICKLE-CELL ANEMIA (3186) ,81-ANEMIA UNSPECIFIED (3) ,82-MALNUTRITION OF MILD DEGREE MALNUTRITION (3187) ,83-MALNUTRITION OF MODERATE DEGREE MALNUTRITION (3188) ,84-OTHER SEVERE PROTEIN-CALORIE MALNUTRITION MALNUTRITION (3189) ,85-KWASHIORKOR MALNUTRITION (1796) ,86-ACQUIRED IMMUNODEFICIENCY SYNDROME UNSPECIFIED SUSPICION SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3190) ,88-ESSENTIAL HYPERTENSION (903) ,91-OTHERS (CANCER HYPERTHYROID ETC.) (3175) ,92-MENINGITIS UNSPECIFIED (1949) ,93-EPILEPSY UNSPECIFIED (1945) ,94-HYSTERIA UNSPECIFIED (1942) ,95-COMA (1800) ,96-CONCUSSION UNSPECIFIED (3171) ,100-LATENT SYPHILIS UNSPECIFIED SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3127) ,102-CHANCROID PLUS CHANCRE (2014) ,103-URETHRAL DISCHARGE (5995) ,104-OTHER ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITHOUT MENTION OF ABSCESS (3129) ,105-OTHER VENEREAL DISEASES SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3130) ,109-HYDROCELE UNSPECIFIED (3132) ,111-UNATTENDED DEATH (3134) "/></td> </tr></obsgroup> </includeIf> </template> <render/> <render/> <render/> <render/> </repeat> </table> </td> </tr> <tr> <td> <table border="1" cellspacing="0" width="95%" align="center"> <tr><td colspan="2" bgcolor="#95ADCA" align="center"><b>MEDIKAMAN</b></td></tr> <tr> <td>PASYAN</td> <td>KOD MEDIKAMAN</td> </tr> <includeIf velocityTest="(($patient.gender == 'F') || ($patient.gender)) && ($patient.gender != 'M')"> <repeat> <template> <obsgroup groupingConceptId="3094" > <tr> <td><obs conceptId="3092" /></td> <td><obs conceptId="3093" answerConceptIds="88,2078,6101,2757,2512,2114,2339,2341,2117,3056,3111,2121,2122,2521,446,2321,2440,2495,2303,2085,2427,2125,2128,2327,2406,3118,351,2425,2490,246,3108,3066,3124,3123,3113,2130,2543,190,907,3114,2416,2415,409,2442,2444,2358,2362,3120,3119,3121,2398,323,2486,3122,2340,3117,3115,944,2779,2368" answerLabels="1-ASPIRIN 75MG (88) ,2-ASPIRIN 500MG (2078) ,3-VITAMIN A 200 000IU (6101) ,4-AMINOPHYLLINE 200MG (2757) ,5-AMOXICILLIN 500MG (2512) ,6-CHLORAMPHENIC 250MG CAP (2114) ,7-CHLOROQUINE 100MG (2339) ,8-CHLOROQUINE 250MG (2341) ,10-CIPROFLOXACIN 500MG (2117) ,11-BACTRIM 20/100 (3056) ,12-BACTRIM 80/400 (3111) ,13-DOXYCYCLINE 100MG (2121) ,14-ERYTHROMYCIN 250MG (2122) ,15-HCTZ 50MG (2521) ,16-ALUMINUM HYDROXIDE (446) ,17-METHYLDOPA 250MG (2321) ,18-METRONIDAZOLE 250MG (2440) ,19-MULTIVITAMIN ADULT (2495) ,20-NYSTATIN VAGINAL (2303) ,21-PARACETAMOL 100MG (2085) ,22-PARACETAMOL 500MG (2427) ,23-PEN VK 125MG (2125) ,24-PEN VK 250MG (2128) ,25-PHENOBARBITAL 50MG (2327) ,26-PROPANTHELINE 15MG (2406) ,27-RESPERPINE 0.25 (3118) ,28-ORS PACKETS (351) ,29-FESO4 + ACID FOLIC (2425) ,31-VITAMIN SYRUP (2490) ,32-PIPERAZINE SYRUP (246) ,33-COUGH SYRUP (3108) ,34-BICILLIN 2.4 MIL.UNT (3066) ,35-WATER FOR INJ. 5ML (3124) ,36-WATER FOR INJ. 10ML (3123) ,37-LIDOCAINE 2% 10ML (3113) ,38-PROCAINE PENICILLIN (2130) ,39-CONCEPTROL TABLETS (2543) ,40-CONDOMS (190) ,41-MEDROXYPROGESTERONE (907) ,42-LOFEMINAL CYCLES (3114) ,43-NORPLANT INSERTS (2416) ,44-OVERETTE CYCLES (2415) ,45-BENZYL BENZOATE 25% (409) ,46-BETADINE SOLUTION (2442) ,47-CHLORHEXIDINE SOLN. (2444) ,48-DESENEX CREAM (2358) ,49-EMUL-O-BALM (2362) ,50-SET SUTURE (3120) ,51-SET PANSEMENT (3119) ,52-SULFADIAZINE 500MG (3121) ,53-TETRACYCLINE OPHT (2398) ,54-GENTIAN VIOLET 1% (323) ,55-ACID FOLIC 5MG (2486) ,56-TYLENOL SYRUP (3122) ,57-CHLOROQUINE SYRUP (2340) ,58-PARACETAMOL 120MG (3117) ,59-NORMAL SALINE (3115) ,60-ANTACID (944) ,61-OXYGENE 3% (2779) ,63-NEOMYCIN (2368) " /> </includeIf> <includeIf velocityTest="$patient.gender == 'M' "> <repeat> <template> <obsgroup groupingConceptId="3094" > <tr> <td><obs conceptId="3092" /></td> <td><obs conceptId="3093" answerConceptIds="88,2078,6101,2757,2512,2114,2339,2341,2117,3056,3111,2121,2122,2521,446,2321,2440,2495,2085,2427,2125,2128,2327,2406,3118,351,2425,2490,246,3108,3066,3124,3123,3113,2130,190,409,2442,2444,2358,2362,3120,3119,3121,2398,323,2486,3122,2340,3117,3115,944,2779,2368" answerLabels="1-ASPIRIN 75MG (88) ,2-ASPIRIN 500MG (2078) ,3-VITAMIN A 200 000IU (6101) ,4-AMINOPHYLLINE 200MG (2757) ,5-AMOXICILLIN 500MG (2512) ,6-CHLORAMPHENIC 250MG CAP (2114) ,7-CHLOROQUINE 100MG (2339) ,8-CHLOROQUINE 250MG (2341) ,10-CIPROFLOXACIN 500MG (2117) ,11-BACTRIM 20/100 (3056) ,12-BACTRIM 80/400 (3111) ,13-DOXYCYCLINE 100MG (2121) ,14-ERYTHROMYCIN 250MG (2122) ,15-HCTZ 50MG (2521) ,16-ALUMINUM HYDROXIDE (446) ,17-METHYLDOPA 250MG (2321) ,18-METRONIDAZOLE 250MG (2440) ,19-MULTIVITAMIN ADULT (2495) ,21-PARACETAMOL 100MG (2085) ,22-PARACETAMOL 500MG (2427) ,23-PEN VK 125MG (2125) ,24-PEN VK 250MG (2128) ,25-PHENOBARBITAL 50MG (2327) ,26-PROPANTHELINE 15MG (2406) ,27-RESPERPINE 0.25 (3118) ,28-ORS PACKETS (351) ,29-FESO4 + ACID FOLIC (2425) ,31-VITAMIN SYRUP (2490) ,32-PIPERAZINE SYRUP (246) ,33-COUGH SYRUP (3108) ,34-BICILLIN 2.4 MIL.UNT (3066) ,35-WATER FOR INJ. 5ML (3124) ,36-WATER FOR INJ. 10ML (3123) ,37-LIDOCAINE 2% 10ML (3113) ,38-PROCAINE PENICILLIN (2130) ,40-CONDOMS (190) ,45-BENZYL BENZOATE 25% (409) ,46-BETADINE SOLUTION (2442) ,47-CHLORHEXIDINE SOLN. (2444) ,48-DESENEX CREAM (2358) ,49-EMUL-O-BALM (2362) ,50-SET SUTURE (3120) ,51-SET PANSEMENT (3119) ,52-SULFADIAZINE 500MG (3121) ,53-TETRACYCLINE OPHT (2398) ,54-GENTIAN VIOLET 1% (323) ,55-ACID FOLIC 5MG (2486) ,56-TYLENOL SYRUP (3122) ,57-CHLOROQUINE SYRUP (2340) ,58-PARACETAMOL 120MG (3117) ,59-NORMAL SALINE (3115) ,60-ANTACID (944) ,61-OXYGENE 3% (2779) ,63-NEOMYCIN (2368) " /> </includeIf> </td> </tr> </obsgroup> </template> <render/> <render/> <render/> <render/> </repeat> <tr> <td colspan="2"><font color="#f9f9f9">.</font></td> <tr> <td>DAT RANDEVOU <obs conceptId="5096" allowFutureDates="true"/></td> <td>DAT REFERAL <obs conceptId="3097" allowFutureDates="true"/></td> </tr> </tr> </table> </td> </tr> </table> <CENTER>MOUN KI SIYEN <encounterProvider role="Health Agent"/> <submit/></CENTER> </htmlform>
HAS-Haiti Hospital Admission Form
<htmlform>
<macros>
lightgrey=#e0e0e0
lightblue=#95ADCA
darkblue=#4444ff
</macros>
<div style="background-color: $lightblue"><b><center>Hospital Admission Form</center></b></div>
<table border="1" width="800px" cellspacing="0" align="center" cellpadding="1">
<tr>
<td colspan="3">
<table border="1" width="100%" valign="middle" cellspacing="0" cellpadding="1" ><tr><td><b>LAST NAME</b></td><td><b>FIRST NAME</b></td><td><b>DATE OF BIRTH</b></td><td><b>DOSSIER #</b> </td></tr>
<tr>
<td><span><lookup expression="patient.personName.familyName"/></span></td>
<td><span><lookup expression="patient.personName.givenName"/></span></td>
<td><span><lookup expression="patient.birthdate"/></span></td>
<td><span><lookup expression="patient.getPatientIdentifier(1)"/></span></td>
</tr>
<tr><td colspan="2"><B>LOCALITY</B></td><td><B>ADDRESS</B></td><td><B>CITY</B></td></tr>
<tr><td colspan="2"><lookup complexExpression="
\#set( $locality = 0 )
\#set( $locality = $personAttributes.get('Tribe') )
\#if( $locality == 0 \|\| $locality == 'no tribe name specified' )
OUT DISTRICT
\#else
$locality
\#end
"/></td>
<td><lookup expression="patient.personAddress.address1"/></td>
<td><lookup expression="patient.personAddress.cityVillage"/></td>
</tr>
<tr><td><B>PATIENT AGE</B></td><td><B>GENDER</B></td><td colspan="2"><B>PARENT (Mother)</B></td></tr>
<tr><td><span> <lookup expression="patient.age"/></span></td>
<td> <span><lookup expression="patient.gender" codePrefix="gender_"/></span></td>
<td colspan="2"><lookup complexExpression="#foreach ( $relationship in $relationshipList )
#if( $relationship.relationshipType.bIsToA == 'Parent' )
#if( \!($relationship.personB.patientId == $patient.patientId ))
#if( $relationship.personB.gender == 'F' )
$relationship.personB.personName
#end
#end
#end
\#end
"/>
</td>
</tr>
</table>
</td><td align="center" valign="middle">
<img src="http://intranet.hashaiti.org:81/image/HASlogo_circle_black_small_whitebackground.gif" />
<br />
<lookup complexExpression="
<img src="[http://intranet.hashaiti.org:81/frontdesk/barre_code.php?string=$]{patient.getPatientIdentifier(1)}"/>
" />
</td>
</tr>
</table>
<table border="1" width="800px" cellspacing="0" align="center" cellpadding="1">
<tr>
<td valign="middle" style="width:220px"><br/><b>Services: </b><br/><br/></td><td style="width:256px">
<obs conceptId="1827" required="true" answerConceptIds="1691,2037,6206,2034,3036,2036,1542,2035,1692,6196,6194" answerLabels="ADULT.ISOLATION,ADULT.SURGERY (GENERAL),CHOLERA,INTERNAL.MEDICINE,MALNUTRITION,OBGYN,OBSERVATION,PEDIATRIC.GENERAL,PEDITRIC.ISOLATION,PEDIATRIC.NEONATAL,PEDIATRIC.SURGERY" />
</td><td ></td>
</tr>
<tr><td><b>Durée de l'hospitalisation:</b><br/>(Duration of Hospitalization)</td><td><b>Du</b> (From)<encounterDate default="today" /></td><td><b>Au</b> (To)<obs conceptId="1829" /></td></tr>
<tr ><td valign="top"><b>Diagnostics(s)<br/></b>(Diagnosis)</td><td colspan="3" >
<obs conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="1" size="80" /><br/>
<obs conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="2" size="80"/><br/>
<obs conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="3" size="80" /><br/>
<obs conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="4" size="80" />
</td></tr>
<tr><td valign="top"><b>Traitement ou Procédure</b><br/>(Treatment or Procedure)</td> <td colspan="3"><obs conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="1" size="80"/><br/>
<br/>
<obs conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="2" size="80"/><br/>
<obs conceptId="2630" size="80" labelText="Non-Coded"/>
</td></tr>
<tr><td valign="top"><b>Transféré à </b><br/>(Tranferred to)</td><td colspan="2"><obs conceptId="1285" /></td></tr>
<tr><td valign="top"><b>Condition à L'éxeat</b><br/>(Status at Discharge)</td><td colspan="3"><obs conceptId="2044" style="radio"/></td></tr>
<tr><td><b>Rendez vous:</b><br/>(Return Visit)</td><td><b>Date de Rendez-vous</b><br/><obs conceptId="5096" allowFutureDates="true" /> </td><td><b> Lieu </b>(Place)<br/><obs conceptId="2639" answers="HAS,Dispensaire HAS,Dispensaire non HAS,HIV/TB Clinic" /></td>
</tr>
<tr>
<td colspan="4" align="center"> <b>Lieu</b> (Location) <encounterLocation default="15" order="15" type="hidden" /> <b>Nom du Medecin</b> (Doctor Name)<encounterProvider role="Provider"/>
<submit />
</td>
</tr>
</table>
</htmlform>