Clinical Visit Form
- Veronica Muthee
Questions | Concepts |
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Patient Details |
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Encounter date ␣␣-␣␣-␣␣␣␣ 📆 | |
Encounter Provider |
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Role |
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Encounter Location |
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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***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 | |
Complaints and History of Complaints |
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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 |
Specify other complaints __________________________________ | |
Onset Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Duration (Days) __________________________________ | |
Chief complaint (text) __________________________________ | |
Past Medication History |
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Past medical & Surgical history narrative __________________________________ | |
Current TPT/ TB Treatment |
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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 | |
Allergies & Adverse Drug Reactions |
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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)
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Severity 🔘 Not graded 🔘 Mild 🔘 Moderate 🔘 Severe 🔘 Life-threatening | |
Date of Onset | |
Action taken 🔘 Continue drug 🔘 Dose adjusted 🔘 Discontinued 🔘 Substitution | |
Family History |
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Family History Narrative __________________________________ | |
Sexual History |
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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 |
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LMP*** ␣␣-␣␣-␣␣␣␣ 📆 | |
Is client pregnant? 🔘 Yes 🔘 No 🔘 Unknown | |
Expected Date of Delivery (EDD) ␣␣-␣␣-␣␣␣␣ 📆 | |
Wants (more) children in the near future? 🔘 Yes 🔘 No 🔘 Unknown | |
Family planning status 🔘 On Family Planning 🔘 Not using Family Planning 🔘 Wants Family Planning | |
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 | |
Current/Desired Family Planning Method (s) ☑️ Condoms ☑️ Vasectomy | |
Social History |
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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***CC | 61675c28-e628-4173-bc65-d5e0df78a6da |
Immunization History |
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Immunizations | workspace-launcher |
Objective History |
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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 |
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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 |
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Current WHO HIV stage 🔘 Unknown 🔘 WHO stage 1 🔘 WHO stage 2 🔘 WHO stage 3 🔘 WHO stage 4 | |
Nutritional Assessment |
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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 |
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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 | 159800 Tuberculosis, review of screening questions
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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 |
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Order Basket Launcher | workspace-launcher |
Upload File or Image | |
Assessment |
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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 |
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Order Basket Launcher | workspace-launcher |
Tuberculosis Preventive Treatment (TPT) |
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Evaluated for tuberculosis prophylaxis 🔘 Not applicable 🔘 Yes 🔘 No | |
Tuberculosis prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 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 |
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 | |
Treatment of TB |
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Tuberculosis treatment plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Change regimen 🔘 Dosing Change 🔘 Stop all | |
Tuberculosis drug treatment start date ␣␣-␣␣-␣␣␣␣ 📆 | |
Tuberculosis treatment end date ␣␣-␣␣-␣␣␣␣ 📆 | |
Prevention of opportunistic infections - PCP |
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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 | |
Prevention of Opportunistic Infections - Cryptococcosis |
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Cryptococcal prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Stop all | |
ART Adherence |
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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 |
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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 |
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Reason for referral (text) | |
Follow-up |
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Next Appointment Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Date medication refill is due ␣␣-␣␣-␣␣␣␣ 📆 | |
General Encounter Notes |
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General Note | |
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