Clinical Visit Form
- Veronica Muthee
- Wamathaga Kamau
JSON File: ct_clinical_visit.json
Questions | Concepts |
|---|---|
Patient Details | Β |
Encounter date β£β£-β£β£-β£β£β£β£ π | |
Encounter Provider | Β |
Role | Β |
Encounter Location | Β |
Scheduled visit (boolean) π Yes π No | |
Visit type π Express pharmacy pickup without clinician visit π Follow-up Visit, Regular | |
Population Category π General population π Key population π Priority population | |
Key Population Type π Intravenous drug user π Man who has sex with men π Prisoners π Sex worker π Transgender Persons | |
Priority Population Type π½ Adolescent Girls & Young Women π½ Client of sex worker π½ Fisher Folk π½ Long-distance truck driver π½ Migrant Workers π½ Non-intravenous drug user π½ Refugee π½ Uniformed Forces π½ Other | |
Complaints and History of Complaints | Β |
History of Presenting Complaints (obsGroup) | |
History of Presenting Complaints | |
Chiel Complaint | |
Specify other complaints __________________________________ | |
Onset Date β£β£-β£β£-β£β£β£β£ π | |
Duration (Days) __________________________________ | |
Chief complaint (text) __________________________________ | |
Past Medication History | Β |
Past medical & Surgical history narrative __________________________________ | |
Current TPT/ TB Treatment | Β |
Currently on treatment for tuberculosis π Yes π No π Unknown | |
Currently on tuberculosis prophylaxis treatment (TPT) π Yes π No π Unknown | |
Previously completed Tuberculosis preventive treatment π Yes π No π Unknown | |
Allergies & Adverse Drug Reactions | Β |
AAllergies | workspace-launcher |
Patient reports adverse drug reaction(s)? π Yes π No π Unknown | |
Medicine Causing Reaction | |
Reaction βοΈ Anaphylaxis βοΈ Angioedema βοΈ Anaemia βοΈ Arrhythmia βοΈ Bronchospasm βοΈ Cough βοΈ Diarrhea βοΈ Dystonia βοΈ Flu-Like Syndrome βοΈ Flushing βοΈ Fever βοΈ GI βοΈ Nausea βοΈ Hypertension βοΈ Hives βοΈ Headache βοΈ Hepatotoxicity βοΈ Hyperuricemia βοΈ Itching βοΈ Mental status change βοΈ Musculoskeletal pain βοΈ Optic Neuritis βοΈ Shortness of breath βοΈ Rash βοΈ Tendon Rupture βοΈ Visual Disturbances βοΈ Vomiting βοΈ Unknown βοΈ Other | 160646 Reaction (to an allergen)
|
Severity π Not graded π Mild π Moderate π Severe π Life-threatening | |
Date of Onset | |
Action taken π Continue drug π Dose adjusted π Discontinued π Substitution | |
Family History | Β |
Family History Narrative __________________________________ | |
Sexual History | Β |
Sexually active? π Yes π No π Currently not sexually active | |
Sex without a condom π Yes π No π Unknown | |
Recent history of a Sexually Transmitted Infection π Yes π No π Unknown | |
Reproductive History | Β |
LMP β£β£-β£β£-β£β£β£β£ π | |
Is client pregnant? π Yes π No π Unknown | |
Expected Date of Delivery (EDD) β£β£-β£β£-β£β£β£β£ π | |
Wants (more) children in the near future? π Yes π No π Unknown | |
Family planning status π On Family Planning π Not using Family Planning π Wants Family Planning | |
Current/Desired Family Planning Method (s) π½ Condoms π½ Diaphragm π½ Emergency contraceptive pills π½ Female condom π½ Female sterilization π½ Hysterectomy π½ Implantable contraceptive π½ Injectable contraceptives π½ Intrauterine device π½ Lactational amenorrhea π½ Levonorgestrel π½ Male condom π½ Medroxyprogesterone acetate π½ Natural family planning π½ Norplant (implantable contraceptive) π½ Oral contraception π½ Sexual abstinence π½ Tubal ligation procedure π½ Vasectomy π½ Other non-coded | |
Current/Desired Family Planning Method (s) βοΈ Condoms βοΈ Vasectomy | |
Social History | Β |
History of Substance Use (Alcohol, Tobacco, Drugs) π Never π Current/Past use | |
Do you smoke cigarettes π Never smoker π Unknown if ever smoked π Smoker π Former smoker | |
Number of years smoked | |
Number of cigarette per day | |
Alcohol use π Never π Currently π In the past | |
Duration in Years*** | |
Substances abused***** βοΈ None βοΈ Barbiturate abuse βοΈ Cannabis Abuse βοΈ Cocaine abuse βοΈ Inhalant abuse βοΈ Khat abuse βοΈ Narcotic abuse βοΈ Opioid abuse | |
History of Recent Travel? π Yes π No | |
Subjective narrative***CC | 61675c28-e628-4173-bc65-d5e0df78a6da |
Immunization History | Β |
Immunizations | workspace-launcher |
Objective History | Β |
General examination findings βοΈ Normal βοΈ Cyanosis βοΈ Dehydration βοΈ Finger Clubbing βοΈ Jaundice βοΈ Lethargic βοΈ Lymph Node Axillary βοΈ Lymph Nodes Inguinal βοΈ Oral thrush βοΈ Oedema βοΈ Wasting βοΈ Nasal Flaring βοΈ Pallor | |
General Examination Notes | |
Systemic Examination | Β |
Physical exam outcome π Normal π Abnormal | |
Reviews of System βοΈ Abdominal βοΈ Cardiovascular βοΈ Central Nervous System βοΈ Head, Ear, Eye, Nose & Throat βοΈ Genitourinary βοΈ Musculoskeletal βοΈ Respiratory βοΈ Skin | |
Abdomen findings βοΈ Abdominal distension βοΈ Abdominal mass βοΈ Splenomegaly βοΈ Hepatomegaly βοΈ Abdominal tenderness | |
Abdomen findings notes | |
CVS findings βοΈ Cardiac murmur βοΈ Cardiac rub βοΈ Elevated blood pressure βοΈ Irregular heartbeat βοΈ Palpitations | |
CVS findings notes | |
CNS findings | |
CNS findings notes | |
Genitourinary findings βοΈ Bleeding βοΈ Genital rashes/Lesions βοΈ Hypospadias βοΈ Inguinal Swelling βοΈ Rectal discharge βοΈ Scrotal mass βοΈ Testicular mass βοΈ Ulceration βοΈ Urethral discharge βοΈ Vaginal discharge βοΈ Genital Warts | |
Genitourinary findings notes | |
HEENT findings βοΈ βοΈ βοΈ βοΈ βοΈ βοΈ βοΈ βοΈ | |
HEENT findings notes | |
Musculoskeletal findings βοΈ Abnormal Posture/Movement βοΈ Deformity βοΈ Pain in Joints βοΈ Heberdens nodes βοΈ Increased of local temperature βοΈ Joint crepitus βοΈ Joint stiffness βοΈ Swelling βοΈ Muscle Wasting βοΈ Muscle weakness βοΈ Pitting/Non pitting oedema βοΈ Restriction of movement βοΈ Tendon sheath crepitus βοΈ Ulcers | 1128 Musculoskeletal exam findings |
Musculoskeletal findings notes | |
Respiratory findings βοΈ Reduced breathing βοΈ Bronchial breathing βοΈ Chest in-drawing βοΈ Crackles βοΈ Dullness βοΈ Grunting βοΈ Respiratory distress βοΈ Stridor βοΈ Wheezing | |
Respiratory findings notes | |
Skin findings βοΈ Abscess βοΈ Hair Loss βοΈ Itching βοΈ Kaposis Sarcoma βοΈ Swelling/Growth βοΈ Skin eruptions/Rashes βοΈ Ulcer | |
Skin findings notes | |
WHO HIV Stage | Β |
Current WHO HIV stage π Unknown π WHO stage 1 π WHO stage 2 π WHO stage 3 π WHO stage 4 | |
Nutritional Assessment | Β |
Nutritional status π Not done π Normal π Severe acute malnutrition π Moderate acute malnutrition π Obesity | |
Nutritional interventions provided π Yes π No π Unknown | |
Nutritional support βοΈ Counseling about infant feeding practices βοΈ Food support βοΈ Micronutrient support βοΈ Therapeutic feeding βοΈ Other (specify) βοΈ None | |
Nutritional plan (text) | |
TB Screening | Β |
TB screening done? π Yes π No π Unknown | |
TB Intensive Case Finding βοΈ Night sweats βοΈ Failure to Gain Weight βοΈ Fever lasting more than three weeks βοΈ Cough lasting more than 2 weeks βοΈ Weight Loss (Abnormal weight loss) βοΈ None | 159800 Tuberculosis, review of screening questions Β |
TB screening outcome π Negative π Positive (Presumptive TB) | |
Action taken - Presumptive TB βοΈ GeneXpert MTB/Rif Ordered βοΈ Sputum for acid fast bacilli ordered βοΈ X-ray, chest ordered | |
Laboratory and Diagnostic Tests | Β |
Order Basket Launcher | workspace-launcher |
Upload File or Image | |
Assessment | Β |
Diagnosis & Problem List | |
Diagnosis | |
Diagnosis certainty π½ Presumptive diagnosis π½ Provisonal diagnosis π½ Confirmed diagnosis π½ Final diagnosis | |
Diagnosis order π Primary π Secondary | |
Diagnosis non-coded | |
Problem List | workspace-launcher |
Treatment/Management Plan | Β |
Order Basket Launcher | workspace-launcher |
Tuberculosis Preventive Treatment (TPT) | Β |
Evaluated for tuberculosis prophylaxis π Not applicable π Yes π No | |
Tuberculosis prophylaxis plan π None π Start drugs π Continue regimen π Stop all | |
Tuberculosis preventive treatment regimen π½ 1 HP Isoniazid + Rifapentine prophylaxis π½ 3HP Rifapentine + Isoniazid π½ 3HR Isoniazid+Rifampicin prophylaxis π½ 4R Rifampicin Monotherapy prophylaxis π½ 6H Isoniazid prophylaxis π½ 9H Isoniazid prophylaxis | |
Date tuberculosis prophylaxis started β£β£-β£β£-β£β£β£β£ π | |
Tuberculosis Preventive Treatment adherence π Good π Poor π Fair π Unknown | |
Date tuberculosis prophylaxis ended β£β£-β£β£-β£β£β£β£ π | |
Reason tuberculosis prophylaxis stopped π Completed π Toxicity, drug π Tuberculosis π Other non-coded | |
Treatment of TB | Β |
Tuberculosis treatment plan π None π Start drugs π Continue regimen π Change regimen π Dosing Change π Stop all | |
Tuberculosis drug treatment start date β£β£-β£β£-β£β£β£β£ π | |
Tuberculosis treatment end date β£β£-β£β£-β£β£β£β£ π | |
Prevention of opportunistic infections - PCP | Β |
Pneumocystis pneumonia prophylaxis plan π None π Start drugs π Continue regimen π Change regimen π Stop all | |
PCP prophylaxis start date β£β£-β£β£-β£β£β£β£ π | |
PCP prophylaxis regimen π Sulfamethoxazole / trimethoprim π Dapsone | |
PCP regimen adherence π Good π Fair π Poor π Unknown | |
Reason for stopping PCP prophylaxis π CD4 count greater than 15% π CD4 count greater than 200 π Toxicity, drug π Other non-coded | |
Prevention of Opportunistic Infections - Cryptococcosis | Β |
Cryptococcal prophylaxis plan π None π Start drugs π Continue regimen π Stop all | |
ART Adherence | Β |
HAART adherence assessment π Good π Fair π Poor π Unknown | |
Reason for Fair/Poor Adherence to HAART π½ Alcohol abuse π½ Concerned about privacy/stigma π½ Depression π½ Felt better and stopped taking medication π½ Felt too ill to take medication π½ Forgot to take medication π½ Lost or ran out of medication π½ Pill burden π½ Shares medications with others π½ Toxicity, drug π½ Transport problems π½ Other non-coded | 160582 Reason for poor treatment adherence |
Referrals | Β |
Referrals ordered π½ None π½ Adherence counseling π½ Alcohol counseling π½ Dental care referral π½ Diagnostic testing and counseling for HIV π½ Disclosure counseling π½ Family planning services π½ Health center hospital π½ Health clinic/post π½ Hospital π½ Inpatient care or hospitalization π½ Maternal and child health program π½ Mental health services π½ Nutritional support π½ Obstetrics and gynecology department π½ Ophthalmology referral π½ Postnatal care referral π½ Prenatal care referral π½ Private health care clinic/facility π½ Private home-based care π½ Psychosocial counseling π½ Referral for antiretroviral therapy π½ Referral for imaging study π½ Referral for opportunistic infection treatment π½ Referral for pregnancy termination π½ Sexually transmitted infection program/clinic π½ Social support services π½ Surgical Outpatient Department π½ Tobacco use counseling π½ Tuberculosis Treatment or DOT Program π½ Voluntary counseling and testing for HIV π½ Other non-coded | Β |
Reason for referral (text) | |
Follow-up | Β |
Next Appointment Date β£β£-β£β£-β£β£β£β£ π | |
Date medication refill is due β£β£-β£β£-β£β£β£β£ π | |
General Encounter Notes | Β |
General Note | |
Β | Β |
Β