Patient Tracing Form✅

Contact Date

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160753 Date of event

Contact Method

🔘 Physical contact/client tracing

🔘 Telephone contact/client tracing

🔘 Other non-coded

166456 Mode of contact/client tracing

• 166457 Physical contact/client tracing

• 166458 Telephone contact/client tracing

• 5622 Other

Contacted Successfully

🔘 Yes

🔘 No

🔘 Unknown

167011 Status of call attempt

• 1065 Yes

• 1066 No

• 1067 Unknown

Reasons for missing an appointment

🔽 Client could not get an off from work/school

🔽 COVID-19 Restrictions

🔽 Exposure to COVID-19

🔽 Had enough medications

🔽 Felt better and stopped taking medication

🔽 Inpatient care or hospitalization

🔽 Patient forgot to attend appointment

🔽 Patient was seen in another health center

🔽 Traveling

🔽 Other

160582 Reason for poor treatment adherence

• CovidRestriction COVID-19 Restrictions

• 165610 Exposure to COVID-19

• 159367 Currently taking medication

• 160586 Felt better and stopped taking medication

• 5485 Inpatient care or hospitalization

• 162192 Patient forgot to attend appointment

• 162888 Patient was seen in another health center

• 124153 Traveling

• 5622 Other

Expected Return Date

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5096 Return visit date

Outcome

Final Tracing Outcome reached (After successful or multiple unsuccessful tracing attempts)

🔘 Yes

🔘 No

160721 Procedure outcome

• 1065 Yes

• 1066 No

Final tracing outcome - Patient

🔘 Dead (Create a Death Form)

🔘 Undocumented/Silent transfer-out (Create a Transfer-Out Form)

🔘 Refused (stopped) treatment (Update ART Therapy Form)

🔘 Interruption in Treatment (Lost to follow-up)

🔘 Currently taking ARV

160433 Patient outcome status

• 160432 Dead

• 160551 Self-referral

• 127750 Refusal of treatment by patient

• 5240 Lost to followup

• 160119 Currently taking ARV

Notes

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165095 General patient note