Visit Summary
Demographics
OpenMRS ID:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Date:
*
Encounter Location:
*
Encounter Location
*
...
Provider Name:
*
Provider's system-id:
*
Visit Details
Visit Type:
*
...
Self (SF)
Treatment Supporter (TS)
Other (give name)
Name of treatment supporter:
*
Is current visit scheduled?
*
...
Yes
No
Vital Signs
Systolic Blood Pressure (mmHg):
Diastolic Blood Pressure (mmHg):
Height (CM):
Weight (KG):
BMI:
Pregnancy
Pregnancy status:
*
...
Pregnant
Not Pregnant
Abortion (AB)
Miscarriage (MC)
Live birth
Still birth
ANC No:
EDD:
*
Date of pregnancy end:
*
Family planning
Family planning status:
*
>
...
Currently using (FP)
Wants (WFP)
Not using (NOFP)
Family planning Methods:
Condoms (C)
Emergency contraceptive pills
Oral contraceptive pills (OC)
Injectables (INJ)
Implant (IMP)
Intrauterine devices (IUD)
Lactational amenorrhea (LAM)
Diaphragm/cervical cap (D)
Fertility awareness/periodic abstinence (FA)
Tubal ligation/female sterilization (TL)
Vasectomy - partner (V)
Spermicide
Undecided
Reason not on family planning:
*
>
...
Wants to get pregnant (WP)
Thinks can't get pregnant (UP)
Not sexually active now (NSex)
Tuberculosis Status
Status:
>
...
No signs
TB Suspected
On treatment
Not done (ND)
Treatment No.:
Potential Side Effects
Reported complains since last visit:
Abdominal pain (AB)
Anaemia (A)
Burning, numb, tingling (BN)
CNS Symptoms (dizzy, anxiety, nightmare, depression)
Diarrhoea (D)
Fat changes (FAT)
Fatigue (F)
Headache (H)
Jaundice (J)
Nausea (N)
Rash (R)
Other
Specify Other symptom:
*
None
New OIs & Other Problems
Does patient report any of the following?
Cough
Difficult breathing (DB)
Dementia/Enceph (DE)
Fever
Genital ulcer disease (GUD)
Immune reconstitution inflammatory syndrome (IRIS)
Mouth Ulceration
Pelvic inflammatory disease (PID)
Pneumonia (P)
Poor weight gain (PWG)
Severe uncomplicated malnutrition (SUM)
Severe complicated malnutrition (SCM)
Thrush - oral
Thrush - vaginal
Tuberculosis (TB)
Ulcers - other
Urethral discharge
Weight loss (W)
Zoster (Z)
Other
Specify Other problems:
None
WHO Stage
Current WHO HIV stage(Pediatric):
*
>
...
Who Stage 1 Pediatric
Who Stage 2 Pediatric
Who Stage 3 Pediatric
Who Stage 4 Pediatric
Current WHO HIV stage(Adult):
*
>
...
Who Stage 1 Adult
Who Stage 2 Adult
Who Stage 3 Adult
Who Stage 4 Adult
Cotrimoxazole
Cotrimoxazole Adherence:
>
...
Good (G)
Fair (F)
Poor (P)
Cotrimoxazole Dispensed:
>
...
Yes
No
Not applicable (N/A)
INH Dispensed
INH Dispensed:
>
...
Yes
No
Not applicable (N/A)
Other Medications Dispensed
Other Medications Dispensed
Drug:
Dose:
Units:
Frequency:
>
...
Once daily
Once daily at bedtime
Once daily in the evening
Once daily in the morning
Twice daily
Thrice daily
Four times daily
Medication duration:
Duration Units:
>
...
Hours
Days
Weeks
Months
ARV Drugs
Adherence:
>
...
Good (G)
Fair (F)
Poor (P)
Reason for poor treatment adherence:
Toxicity/side effects (1)
Shares medications with others (2)
Forgot to take medication (3)
Felt better and stopped taking medication (4)
Felt too ill to take medication (5)
Stigma, disclosure or privacy issues (6)
Drug stock out at dispensary (7)
Patient lost/ran out of pills (8)
Delivery/travel problems (9)
Inability to pay (10)
Alcohol abuse (11)
Depression (12)
Pill burden (13)
Other
Specify Other reasons:
Regimen Duration:
Regimen Duration Units:
...
Seconds
Minutes
Hours
Days
Weeks
Months
Years
Number of occurrences
Laboratory Investigations Done
CD4 Count:
Will record CD4 count by ...
...
Count
Percentage
CD4 count :
CD4 count (%) :
Hemoglobin :
RPR:
>
...
Negative
Positive
Unknown
TB Sputum:
>
...
Scanty
+
++
+++
Negative
Other Tests:
Urine Tests:
Urinalysis Order
Urinalysis Order
Test result:
*
>
...
Normal
Abnormal
Unknown
Date Collected:
*
Urine Pregnancy Test
Urine Pregnancy Test
Test result:
*
>
...
Negative
Positive
Indeterminate
Poor sample quality
Date Collected:
*
Blood Tests:
Lymphocyte Count
Lymphocyte Count
Test result:
*
Date Collected:
*
HIV Viral Load
HIV Viral Load
Test result:
*
Date Collected:
*
Erythrocyte Sedimentation Rate
Erythrocyte Sedimentation Rate
Test result:
*
Date Collected:
*
Referral ordered & Hospitalization
Which referrals were ordered?
Adherence Counseling
Alcohol Counselling
ARV for mother
ARV Therapy
Dental Care
Diagnostic Testing and Counseling for HIV
Disclosure Counseling
Imaging Study
Inpatient Care or Hospitalization
Family Planning services
Nutritional Support
Mental Health Services
Ophthalmology
Opportunistic infection treatment
Pregnancy termination
Prenatal Care
Private health care clinic/facility
Private home-based care
Postnatal Care
Psychosocial Counseling
Tobacco Use Counseling
Sexually transmitted infection program/clinic
Tuberculosis Treatment or DOT Program
VCT HIV
Other
Specify Other referrals ordered:
*
None
Days hospitalized :
At Risk Population
To which risk population does the patient belong?
Discordant Couple
Male who has sex with men
Injectable drug User (IDU)
Sex worker (SW)
Client of sex worker (cSW)
Long distance truck driver
Not Applicable
PwP Services
HIV status disclosed to partner:
>
...
Yes
No
Partner HIV tested:
>
...
Yes
No
Condoms given during the visit:
>
...
Yes
No
Patient tested for sexually transmitted illness in current visit:
>
...
Yes
No
Next Appointment
Date of next appointment:
*