Clinical Visit Form

JSON File: ct_clinical_visit.json

Questions	Concepts

Questions	Concepts
Patient Details
Encounter date ␣␣-␣␣-␣␣␣␣ 📆	163137 Encounter start date/time
Encounter Provider
Role
Encounter Location
Scheduled visit (boolean) 🔘 Yes 🔘 No	1246 Scheduled visit 1065 Yes 1066 No
Visit type 🔘 Express pharmacy pickup without clinician visit 🔘 Follow-up Visit, Regular	164181 Visit type 166446 Express pharmacy pickup without clinician visit 160523 Follow-up visit, regular
Population Category 🔘 General population 🔘 Key population 🔘 Priority population	166432 Study population type 166430 General population 166431 Target population 167143 Priority Population
Key Population Type 🔘 Intravenous drug user 🔘 Man who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons	166433 Target population type 157351 Intravenous drug user 160578 Male who has sex with men 162277 In prison 160579 Sex worker 166415 Transgender status
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	166433 Target population type 166043 Late adolescent/young adulthood period 160580 Client of sex worker 159674 Fisherman 162198 Long-distance truck driver 169409 Migrant worker 166514 Non-intravenous drug user 164100 Refugee 169461 Uniformed services 5622 Other
Complaints and History of Complaints
History of Presenting Complaints (obsGroup)	1727 Signs and symptoms
History of Presenting Complaints	1390 History of present illness
Chiel Complaint ☑️ 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	5219 Chief complaint 151 Abdominal pain 141631 Dysfunctional Uterine Bleeding 121543 Anxiety 148035 Back pain 840 Hematuria 117671 Hematochezia 131021 Pain of breast 120749 Chest pain 871 Chills 120345 Confusion 143264 Cough 113054 Convulsions 144576 Coma 106 Acute Coryza 143129 Crying Infant 119574 Delirium 119537 Depression 142412 Diarrhea 122496 Dyspnea 118789 Dysphagia 142247 Discharge from Penis 141830 Dizziness and Giddiness 141585 Ear Problem 141128 Epigastric pain 131040 Pain in Eye 140941 Excessive Sweating 114399 Facial Pain 162626 Intense fatigue and general weakness 140070 Flank Pain 140238 Fever 135462 Lymphogranuloma venereum 139084 Headache 117698 Hearing Loss 116214 Hypotension 879 Pruritus 116558 Pain in Joint 114395 Leg pain 116334 Lethargy 135595 Loss of Appetite 135488 Lymphadenopathy 121657 Memory Loss 111721 Mouth ulceration 131015 Painful Mouth 133028 Muscle Cramp, Nocturnal 133632 Muscle pain 121 Myalgia 5978 Nausea 133469 Neck Pain 133027 Night sweats 132653 Numbness of Foot 162628 Unexplained bleeding 125225 Swallowing painful 131034 Pain in pelvis 5953 Vision difficulties 512 Rash 127777 Red eye 6017 Refusal to feed 113224 Rhinitis 131032 Pain in Scrotum 206 Seizure 126535 Shoulder Pain 112989 Shock 158843 Sore throat 141597Dyssomnia 125198 Swollen Feet 112200 Tremor 160208 Urinary symptoms 157498 Limb weakness 832 Weight loss 123396 Vaginal discharge 122983 Vomiting 111525 Vertigo 5622 Other
Specify other complaints __________________________________	160531 Chief complaint (text)
Onset Date ␣␣-␣␣-␣␣␣␣ 📆	1730 Sign/symptom start date
Duration (Days) __________________________________	1731 Sign/symptom duration
Chief complaint (text) __________________________________	160531 Chief complaint (text)
Past Medication History
Past medical & Surgical history narrative __________________________________	165095 General patient note
Current TPT/ TB Treatment
Currently on treatment for tuberculosis 🔘 Yes 🔘 No 🔘 Unknown	159798 Currently on tuberculosis treatment 1065 Yes 1066 No 1067 Unknown
Currently on tuberculosis prophylaxis treatment (TPT) 🔘 Yes 🔘 No 🔘 Unknown	166449 Currently taking tuberculosis prophylaxis 1065 Yes 1066 No 1067 Unknown
Previously completed Tuberculosis preventive treatment 🔘 Yes 🔘 No 🔘 Unknown	166463 Completed course of tuberculosis prophylaxis 1065 Yes 1066 No 1067 Unknown
Allergies & Adverse Drug Reactions
AAllergies	workspace-launcher
Patient reports adverse drug reaction(s)? 🔘 Yes 🔘 No 🔘 Unknown	1512 Allergy to drug 1065 Yes 1066 No 1067 Unknown
Medicine Causing Reaction	1193 Current drugs used
Reaction ☑️ Anaphylaxis ☑️ Angioedema ☑️ Anaemia ☑️ Arrhythmia ☑️ Bronchospasm ☑️ Cough ☑️ Diarrhea ☑️ Dystonia ☑️ Flu-Like Syndrome ☑️ Flushing ☑️ Fever ☑️ GI ☑️ 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) 148888 Anaphylaxis 148787 Angioedema 121629 Anaemia 120148 Arrhythmia 108 Bronchospasm 143264 Cough 142412 Diarrhea 118773 Dystonia 137162 Influenza-like symptoms 140039 Flushing 140238 Fever 5978 Nausea 139581 GI upset ***** 117399 Hypertension 111061 Hives 139084 Headache 159098 Hepatotoxicity 138111 Hyperuricaemia 879 Pruritus 121677 Mental status change 159347 Musculoskeletal pain 114736 Optic Neuritis 141600 Shortness of breath 512 Rash 113180 Rupture of Achilles tendon 123074 Visual disturbance 122983 Vomiting 1067 Unknown 5622 Other**
Severity 🔘 Not graded 🔘 Mild 🔘 Moderate 🔘 Severe 🔘 Life-threatening	162760 Severity of adverse reaction 1067 Unknown 1498 Mild 1499 Moderate 1500 Severe 162819 Fatal
Date of Onset	160753 Date of event
Action taken 🔘 Continue drug 🔘 Dose adjusted 🔘 Discontinued 🔘 Substitution	1255 Antiretroviral plan 1257 Continue regimen 981 Dosing change 1260 Stop all 1259 Change regimen
Family History
Family History Narrative __________________________________	160618 Family history comment
Sexual History
Sexually active? 🔘 Yes 🔘 No 🔘 Currently not sexually active	160109 Sexually active 1065 Yes 1066 No 160573 Currently not sexually active
Sex without a condom 🔘 Yes 🔘 No 🔘 Unknown	166658 Had sex without condom 1065 Yes 1066 No 1067 Unknown
Recent history of a Sexually Transmitted Infection 🔘 Yes 🔘 No 🔘 Unknown	169004Sexually transmitted infection (STI) in past 6 months 1065 Yes 1066 No 1067 Unknown
Reproductive History
LMP ␣␣-␣␣-␣␣␣␣ 📆	1427 Date of last menstrual period
Is client pregnant? 🔘 Yes 🔘 No 🔘 Unknown	5272 Pregnancy status 1065 Yes 1066 No 1067 Unknown
Expected Date of Delivery (EDD) ␣␣-␣␣-␣␣␣␣ 📆	5596 Estimated date of confinement
Wants (more) children in the near future? 🔘 Yes 🔘 No 🔘 Unknown	160571 Patient wishes to get pregnant 1065 Yes 1066 No 1067 Unknown
Family planning status 🔘 On Family Planning 🔘 Not using Family Planning 🔘 Wants Family Planning	160653 Family planning status 965 Currently using birth control 160652 Patient not using family planning 1360 Requests family planning information
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	374 Method of family planning
Current/Desired Family Planning Method (s) ☑️ Condoms ☑️ Vasectomy	374 Method of family planning 190 Condoms 1489 Vasectomy
Social History
History of Substance Use (Alcohol, Tobacco, Drugs) 🔘 Never 🔘 Current/Past use	160246 Substance use 1090 Never 1065 Yes
Do you smoke cigarettes 🔘 Never smoker 🔘 Unknown if ever smoked 🔘 Smoker 🔘 Former smoker	163201 Smoking status 163198 Never smoker 163200 Unknown if ever smoked 152722 Smoker 152807 Former smoker
Number of years smoked	159931 Duration of smoking (in years)
Number of cigarette per day	1546 Daily cigarette use
Alcohol use 🔘 Never 🔘 Currently 🔘 In the past	159449 Alcohol use status 1090 Never 159450 Currently 159452 In the past
Duration in Years***	1546 Daily cigarette use** 166361 Duration of alcohol use (years)**
Substances abused***** ☑️ None ☑️ Barbiturate abuse ☑️ Cannabis Abuse ☑️ Cocaine abuse ☑️ Inhalant abuse ☑️ Khat abuse ☑️ Narcotic abuse ☑️ Opioid abuse	112603 Substance abuse 1107 None 121249 Barbiturate abuse 146504 Cannabis Abuse 144661 Cocaine abuse 116945 Inhalant abuse 159779 Khat abuse 114751 Narcotic abuse 114750 Opioid abuse
History of Recent Travel? 🔘 Yes 🔘 No	165656 History of recent travel in past 14 days 1065 Yes 1066 No
Subjective narrativeCC*	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	162737Physical exam outcome 1107 None??? why not 1115Normal 143050 Cyanosis 142630 Dehydration 140125 Finger Clubbing 136443 Jaundice 116334 Lethargy 160613 Axillary lymph node location 160680 Inguinal lymph node(s) 5334 Candidiasis, oral 460 Oedema 823 Wasting syndrome 1861 Nostril flaring 5245 Pallor
General Examination Notes	163042 General examination (text)
Systemic Examination
Physical exam outcome 🔘 Normal 🔘 Abnormal	162737 Physical exam outcome 1115 Normal 1116 Abnormal
Reviews of System ☑️ Abdominal ☑️ Cardiovascular ☑️ Central Nervous System ☑️ Head, Ear, Eye, Nose & Throat ☑️ Genitourinary ☑️ Musculoskeletal ☑️ Respiratory ☑️ Skin	159615 Review of systems 160947 Abdominal examination (text) 163046 Cardiac examination (text) 163109 Nervous system examination (text) 163045 HEENT examination (text) 163047 Urogenital examination (text) 163048 Musculoskeletal examination (text) 160689 Chest examination (text) 160981 Skin examination (text)
Abdomen findings ☑️ Abdominal distension ☑️ Abdominal mass ☑️ Splenomegaly ☑️ Hepatomegaly ☑️ Abdominal tenderness	1125 Abdominal exam findings 150915 Abdominal distension 5103 Abdominal mass 5009 Splenomegaly 5008 Hepatomegaly 5105 Abdominal tenderness
Abdomen findings notes	160947 Abdominal examination (text)
CVS findings ☑️ Cardiac murmur ☑️ Cardiac rub ☑️ Elevated blood pressure ☑️ Irregular heartbeat ☑️ Palpitations	1124 Cardiac exam findings 562 CARDIAC MURMUR (on exam) 130560 Pericardial friction rub 140147 Elevated blood pressure 136522 Irregular heartbeat 130987 Palpitations
CVS findings notes	163046 Cardiac examination (text)
CNS findings ☑️ Abnormal reflexes ☑️ Altered sensations ☑️ Brudzinski's sign ☑️ Bulging fontenelle ☑️ Confusion ☑️ Kernicterus ☑️ Limb weakness ☑️ Loss of consciousness ☑️ Stiff neck	1129 Neurologic exam findings 150817 Abnormal Reflex 118872 Alterations of Sensations 153009 Babinski Sign 1836 Bulging fontenelle 120345 Confusion 136282 Kernicterus not due to Isoimmunisation 157498 Limb weakness 135592 Loss of consciousness 112721 Stiffness of neck
CNS findings notes	163109 Nervous system examination (text)
Genitourinary findings ☑️ Bleeding ☑️ Genital rashes/Lesions ☑️ Hypospadias ☑️ Inguinal Swelling ☑️ Rectal discharge ☑️ Scrotal mass ☑️ Testicular mass ☑️ Ulceration ☑️ Urethral discharge ☑️ Vaginal discharge ☑️ Genital Warts	1126 Urogenital exam findings 147241 Bleeding 117829 Genital herpes 138010 Hypospadias 125207 Swelling of Inguinal Region 154311 Rectal discharge 113122 Scrotal Mass 124965 Testicular Mass 124087 Tropical Ulcer 123529 Urethrorrhoea 123396 Vaginal discharge 139505 Genital warts
Genitourinary findings notes	163047 Urogenital examination (text)
HEENT findings ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️	1122 HEENT exam findings
HEENT findings notes	163045 HEENT examination (text)
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 150823 Abnormal Posture 155871 Deformity 116557 Pain in Joints 139047 Heberden's Node 165282 Increased skin temperature 136421 Joint Crepitus 116554 Stiffness of joint 163894 Swelling 163851 Quadriceps muscle wasting 115476 Muscle Weakness 130166 Pitting Edema 135786 Limitation of Joint Movement 152959 Thickening of Tendon Sheath 123919 Ulcer
Musculoskeletal findings notes	163048 Musculoskeletal examination (text)
Respiratory findings ☑️ Reduced breathing ☑️ Bronchial breathing ☑️ Chest in-drawing ☑️ Crackles ☑️ Dullness ☑️ Grunting ☑️ Respiratory distress ☑️ Stridor ☑️ Wheezing	1123 Chest exam findings 164440 Breathing poorly (<30 breaths / min) 146893 Bronchial Breathing 136768 Intercostal recession 127640 Respiratory crackles 145712 Abnormal Dullness to Percussion of Chest 156534 Grunting baby 127639 Respiratory Distress 136790 Inspiratory Stridor 122864 Wheeze - rhonchi
Respiratory findings notes	160689 Chest examination (text)
Skin findings ☑️ Abscess ☑️ Hair Loss ☑️ Itching ☑️ Kaposis Sarcoma ☑️ Swelling/Growth ☑️ Skin eruptions/Rashes ☑️ Ulcer	1120 Skin exam findings 150555 Abscess of skin and subcutaneous tissue 135591 Loss of Hair 136455 Itching 507 Kaposi's sarcoma of skin 125201 Swelling of Skin 1249 Papular pruritic eruption 123919 Ulcer
Skin findings notes	160981 Skin examination (text)
WHO HIV Stage
Current WHO HIV stage 🔘 Unknown 🔘 WHO stage 1 🔘 WHO stage 2 🔘 WHO stage 3 🔘 WHO stage 4	5356 Current WHO HIV stage 1067 Unknown 1204 WHO stage 1 adult 1205 WHO stage 2 adult 1206 WHO stage 3 adult 1207 WHO stage 4 adult
Nutritional Assessment
Nutritional status 🔘 Not done 🔘 Normal 🔘 Severe acute malnutrition 🔘 Moderate acute malnutrition 🔘 Obesity	167392 Nutritional status 1118 Not done 1115 Normal 163302 Severe acute malnutrition 163303 Moderate acute malnutrition 115115 Obesity
Nutritional interventions provided 🔘 Yes 🔘 No 🔘 Unknown	1380 Nutrition counseling 1065 Yes 1066 No 1067 Unknown
Nutritional support ☑️ Counseling about infant feeding practices ☑️ Food support ☑️ Micronutrient support ☑️ Therapeutic feeding ☑️ Other (specify) ☑️ None	5484 Nutritional support 161651 Counseling about infant feeding practices 161648 Food support 161649 Micronutrient support 161650 Therapeutic feeding 5622 Other 1107 None
Nutritional plan (text)	163189 Nutritional plan (text)
TB Screening
TB screening done? 🔘 Yes 🔘 No 🔘 Unknown	164800 Screened for tuberculosis 1065 Yes 1066 No 1067 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 133027 Night sweats 140707 Failure to Gain Weight 140238 Fever 159799 Cough lasting more than 2 weeks 1858 Recent weight loss 1107 None
TB screening outcome 🔘 Negative 🔘 Positive (Presumptive TB)	160108 Screening test result, tuberculosis 664 Negative 703 Positive
Action taken - Presumptive TB ☑️ GeneXpert MTB/Rif Ordered ☑️ Sputum for acid fast bacilli ordered ☑️ X-ray, chest ordered	166937 Care management plan 164945 GeneXpert MTB/Rif Lab set 307 Sputum for acid fast bacilli 12 X-ray, chest
Laboratory and Diagnostic Tests
Order Basket Launcher	workspace-launcher
Upload File or Image	1238 Medical record observations
Assessment
Diagnosis & Problem List	159947 Visit Diagnoses
Diagnosis	1284 Problem list
Diagnosis certainty 🔽 Presumptive diagnosis 🔽 Provisonal diagnosis 🔽 Confirmed diagnosis 🔽 Final diagnosis	159394 Diagnosis certainty 159393 Presumed diagnosis 160249 Provisional diagnosis 159392 Confirmed diagnosis 160250 Final diagnosis
Diagnosis order 🔘 Primary 🔘 Secondary	159946 Diagnosis order 159943 Primary 159944 Secondary
Diagnosis non-coded	161602 Diagnosis or problem, non-coded
Problem List	workspace-launcher
Treatment/Management Plan
Order Basket Launcher	workspace-launcher
Tuberculosis Preventive Treatment (TPT)
Evaluated for tuberculosis prophylaxis 🔘 Not applicable 🔘 Yes 🔘 No	162275 Evaluated for tuberculosis prophylaxis 1175 Not applicable 1065 Yes 1066 No
Tuberculosis prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Stop all	1265 Tuberculosis prophylaxis plan 1107 None 1256 Start drugs 1257 Continue regimen 1260 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	1264 Tuberculosis prophylaxis started 169413 Isoniazid + rifapentine prophylaxis - one month (1HP) 169415 Isoniazid + Rifapentine prophylaxis - three months (3HP) 169412Isoniazid + rifampicin prophylaxis - three months (3HR) 169414 Rifampicin monotherapy prophylaxis - four months (4R) 169411 Isoniazid prophylaxis - six months (6H) 169410 Isoniazid prophylaxis - nine months (9H)
Date tuberculosis prophylaxis started ␣␣-␣␣-␣␣␣␣ 📆	162320 Date started on tuberculosis prophylaxis
Tuberculosis Preventive Treatment adherence 🔘 Good 🔘 Poor 🔘 Fair 🔘 Unknown	161653 Isoniazid adherence 159405 Good 159407 Poor 159406 Fair 1067 Unknown
Date tuberculosis prophylaxis ended ␣␣-␣␣-␣␣␣␣ 📆	163284 Date tuberculosis prophylaxis ended
Reason tuberculosis prophylaxis stopped 🔘 Completed 🔘 Toxicity, drug 🔘 Tuberculosis 🔘 Other non-coded	1266 Reason tuberculosis prophylaxis stopped 1267 Completed 102 Toxicity, drug 112141 Tuberculosis 5622 Other
Treatment of TB
Tuberculosis treatment plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Change regimen 🔘 Dosing Change 🔘 Stop all	1268 Tuberculosis treatment plan 1107 None 1256 Start drugs 1257 Continue regimen 1259 Change regimen 981 Dosing change 1260 Stop all
Tuberculosis drug treatment start date ␣␣-␣␣-␣␣␣␣ 📆	1113 Tuberculosis drug treatment start date
Tuberculosis treatment end date ␣␣-␣␣-␣␣␣␣ 📆	159431 Tuberculosis treatment end date
Prevention of opportunistic infections - PCP
Pneumocystis pneumonia prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Change regimen 🔘 Stop all	1261 PCP prophylaxis plan 1107 None 1256 Start drugs 1257 Continue regimen 1259 Change regimen 1260 Stop all
PCP prophylaxis start date ␣␣-␣␣-␣␣␣␣ 📆	164361Cotrimoxazole prophylaxis start date
PCP prophylaxis regimen 🔘 Sulfamethoxazole / trimethoprim 🔘 Dapsone	1109Patient reported current PCP prophylaxis 105281 Sulfamethoxazole / trimethoprim 74250 Dapsone
PCP regimen adherence 🔘 Good 🔘 Fair 🔘 Poor 🔘 Unknown	166462 Pneumocystis carinii pneumonia prophylaxis adherence 159405 Good 159406 Fair 159407 Poor 1067 Unknown
Reason for stopping PCP prophylaxis 🔘 CD4 count greater than 15% 🔘 CD4 count greater than 200 🔘 Toxicity, drug 🔘 Other non-coded	1262 Reason PCP prophylaxis stopped 982 CD4 count greater than 15% 1254 CD4 count greater than 200 102 Toxicity, drug 5622 Other
Prevention of Opportunistic Infections - Cryptococcosis
Cryptococcal prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Stop all	1277 Cryptococcal treatment plan 1107 None 1256 Start drugs 1257 Continue regimen 1260 Stop all
ART Adherence
HAART adherence assessment 🔘 Good 🔘 Fair 🔘 Poor 🔘 Unknown	1164 Antiretroviral adherence in past week 159405 Good 159406 Fair 159407 Poor 1067 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 121725 Alcohol abuse 160589 Concerned about privacy/stigma 119537 Depression 160586 Felt better and stopped taking medication 160585 Felt too ill to take medication 160587 Forgot to take medication 160584 Lost or ran out of medication 160588 Pill burden 160583 Shares medications with others 102 Toxicity, drug 820 Transport problems 5622 Other
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	1272 Referrals ordered
Reason for referral (text)	164359 Reason for referral (text)
Follow-up
Next Appointment Date ␣␣-␣␣-␣␣␣␣ 📆	5096 Return visit date
Date medication refill is due ␣␣-␣␣-␣␣␣␣ 📆	162549 Date medication refills due
General Encounter Notes
General Note	162169 Text of encounter note

Documentation

Clinical Visit Form

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