Patient Tracing Form✅
- Veronica Muthee
JSON File: ct_patient_tracing.json
Questions | Concepts |
|---|---|
Contact attempt detail | |
Contact Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Contact Method 🔘 Physical contact/client tracing 🔘 Telephone contact/client tracing 🔘 Other non-coded | |
Contacted Successfully 🔘 Yes 🔘 No 🔘 Unknown | |
Reasons for missing an appointment 🔽 Unable to get time off from work or school 🔽 Public health restrictions 🔽 Exposure to COVID-19 🔽 Had sufficient 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 | 169482 Reason for missed visit (coded) |
Expected Return Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Outcome |
|
Final Tracing Outcome reached (After successful or multiple unsuccessful tracing attempts) 🔘 Yes 🔘 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 | |
Notes __________________________________ |