ID

16120

Beschrijving

Form issued by Binyam Tilahun. Source: http://www.moh.gov.et/ (Ministry of Health, Ethiopia)

Link

http://www.moh.gov.et/

Trefwoorden

Versies (1)
  1. 30-06-16 30-06-16 -
Geüploaded op

30 juni 2016

DOI

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Licentie

Creative Commons BY-NC 3.0
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Ministry of Health,Ethiopia-HIV Care/ART Follow up

Engels

HIV Care/ART Follow up

1 Formulieren  
  1. StudyEvent: ODM
    1. HIV Care/ART Follow up
Demographics
Beschrijving

Demographics

Facility name
Beschrijving

Facility name

Datatype

text

Alias
UMLS CUI [1,1]
C0018704
UMLS CUI [1,2]
C0027365
Patient card number
Beschrijving

Patient card number

Datatype

integer

Alias
UMLS CUI [1,1]
C0030705
UMLS CUI [1,2]
C1549704
ART unique number
Beschrijving

ART unique number

Datatype

integer

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C2735568
Tuberculosis Card number
Beschrijving

Tuberculosis Card number

Datatype

integer

Alias
UMLS CUI [1,1]
C0041296
UMLS CUI [1,2]
C1549704
PMTCT Confidentiality Code
Beschrijving

PMTCT Confidentiality Code

Datatype

integer

Alias
UMLS CUI [1,1]
C3845698
UMLS CUI [1,2]
C1547595
Patient´s Name
Beschrijving

Patient Name

Datatype

text

Alias
UMLS CUI [1]
C1299487
Age
Beschrijving

Months for children younger than 5 years

Datatype

integer

Maateenheden
  • years
Alias
UMLS CUI [1]
C0001779
years
Gender
Beschrijving

Gender

Datatype

integer

Alias
UMLS CUI [1]
C0079399
Body height
Beschrijving

Adults

Datatype

float

Maateenheden
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Patient address: Region
Beschrijving

Patient address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Patient address: Wereda/Subcity
Beschrijving

Patient address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Patient address: Kebele
Beschrijving

Patient address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Patient address: House number
Beschrijving

Patient address

Datatype

integer

Alias
UMLS CUI [1]
C0421449
Telephone number
Beschrijving

Telephone

Datatype

integer

Alias
UMLS CUI [1]
C1515258
Date HIV positivity confirmed
Beschrijving

Date HIV positivity confirmed

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0019699
UMLS CUI [1,3]
C0750484
HIV Test Type
Beschrijving

HIV Test Type

Datatype

integer

Alias
UMLS CUI [1,1]
C0459958
UMLS CUI [1,2]
C0449570
Eligibility Date
Beschrijving

Eligibility Date

Datatype

date

Alias
UMLS CUI [1]
C1976613
Why eligible? Please select
Beschrijving

Eligibility criteria

Datatype

integer

Alias
UMLS CUI [1]
C0013893
Please enter the date when patient is medically eligible and ready (counseled for adherence) for ART
Beschrijving

Date eligible and ready

Datatype

date

Alias
UMLS CUI [1,1]
C1829734
UMLS CUI [1,2]
C0010210
Follow up chart
Beschrijving

Follow up chart

Please specify whether patient receives free ART or pays for ART
Beschrijving

Payment status

Datatype

integer

Alias
UMLS CUI [1]
C0585761
Visit Type
Beschrijving

Visit

Datatype

text

Alias
UMLS CUI [1]
C0545082
Follow up date
Beschrijving

Follow-Up date

Datatype

date

Alias
UMLS CUI [1]
C3694716
Months on ART
Beschrijving

0= ART initiation date 1 week=1 week 2 weeks=2 weeks 3 weeks=3weeks 1= 1 month 2= 2 months ... If Pre-ART, leave this column blank

Datatype

text

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C1976623
Weight
Beschrijving

Weight

Datatype

float

Maateenheden
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Pregnancy
Beschrijving

Pregnancy

Datatype

boolean

Alias
UMLS CUI [1]
C0032961
If pregnant, please specify estimated due date
Beschrijving

Estimated due date

Datatype

date

Alias
UMLS CUI [1]
C2825543
Family planning method
Beschrijving

Contraceptive method

Datatype

integer

Alias
UMLS CUI [1]
C0700589
Height of child
Beschrijving

Height

Datatype

float

Maateenheden
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Head circumference
Beschrijving

Head circumference

Datatype

float

Maateenheden
  • cm
Alias
UMLS CUI [1]
C0262499
cm
Patient functional status
Beschrijving

Functional status

Datatype

text

Alias
UMLS CUI [1]
C0598463
Developmental milestones
Beschrijving

A= sitting without support 3-9months,Standing with assistance 5-11 months,Hand and knees crawling 6-13 months, walking with assistance 7-14 months, standing alone 8-17 months, walking alone 9-18 months D= failure to attain above milestones for age R=Loss of what has been attained for age

Datatype

text

Alias
UMLS CUI [1]
C2983568
WHO human immunodeficiency virus stage
Beschrijving

WHO Stage

Datatype

integer

Alias
UMLS CUI [1]
C1976611
Tuberculosis screening
Beschrijving

1:Cough > 2 weeks 2: Fever > 2 weeks 3:Weight loss > 3kg since last visit 4:Night sweat > 2 weeks 5: History of TB contact within last year P= Yes to Q1 or No to Q1 but Yes to 2 or more other Q N= negative screen

Datatype

integer

Alias
UMLS CUI [1]
C0420004
Tuberculosis prophylaxis
Beschrijving

Tuberculosis prophylaxis

Datatype

text

Alias
UMLS CUI [1]
C0740413
Tuberculosis prophylaxis:please specify months on treatment
Beschrijving

i.e INH4= 4th month on treatment, on completion of prophylaxis= INH DC; TBRx4= 4th month on DOTS, on completion of DOTS = TBRx DC

Datatype

text

Alias
UMLS CUI [1]
C0740413
Other Infections
Beschrijving

Other infections

Datatype

text

Alias
UMLS CUI [1]
C0009450
Cotrimoxazole
Beschrijving

Cotrimoxazole

Datatype

boolean

Alias
UMLS CUI [1]
C0041044
Dispensed dose, please note the number of dispensed doses
Beschrijving

Cotrimoxazole dispensed dose

Datatype

integer

Alias
UMLS CUI [1,1]
C0041044
UMLS CUI [1,2]
C0805077
Therapy adherence
Beschrijving

Good=>95% of doses- of 30 <= 2 doses missed; of 60 doses <3 doses missed Fair= 85-94% of doses- of 30 doses 3-5 doses missed; of 60 doses 3-9 doses missed Poor=<85% of doses- of 30 doses >= 6 doses missed; of 60 doses > 9 doses missed

Datatype

text

Alias
UMLS CUI [1]
C1321605
If fair or poor therapy adherence, please specify reason
Beschrijving

Adherence

Datatype

integer

Alias
UMLS CUI [1]
C1321605
Any other medication dispensed
Beschrijving

Other Medication

Datatype

text

Alias
UMLS CUI [1]
C0013227
Antiretroviral therapy adherence
Beschrijving

Antiretroviral therapy adherence

Datatype

text

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C1321605
If therapy adherence is fair or poor,please specify why
Beschrijving

Antiretroviral therapy adherence

Datatype

text

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C1321605
Antiretroviral therapy Dispense code
Beschrijving

Adult first line regimen 1a(30)=d4t(30)-3TC-NVP 1a(40)=d4t(40)-3TC-NVP 1b(30)=d4t(30)-3TC-EFV 1b(40)=d4t(40)-3TC-EFV Adult second line regimen 2a=ABC-ddl-LPV/r 2b=ABC-ddl-NFV 2c=TDF-ddl-LPV/R 2d=TDF-ddl-NFV 1c=AZT-3TC-NVP 1d=AZT-3TC-EFV

Datatype

text

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C2735568
Antiretroviral therapy Dispense code
Beschrijving

Adult first line regimen 4a=d4t-3TC-NVP 4b=d4t-3TC-EFV 4c=AZT-3TC-NVP 4d=AZT-3TC-EFV Child second line regimen 5a=ABC-ddl-LPV/r 5b=ABC-ddl-NFV 5c=TDF-ddl-LPV/R 5d=TDF-ddl-NFV

Datatype

text

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C2735568
Antiretroviral therapy dispensed dose
Beschrijving

Antiretroviral therapy dispensed dose

Datatype

integer

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C0805077
Antiretroviral therapy side effects
Beschrijving

Antiretroviral therapy side effects

Datatype

integer

Alias
UMLS CUI [1,1]
C1963724
UMLS CUI [1,2]
C0879626
Reason for change of treatment
Beschrijving

Reason for change

Datatype

integer

Alias
UMLS CUI [1,1]
C1299575
UMLS CUI [1,2]
C0392360
Reason for treatment stop
Beschrijving

Reason for treatment stop

Datatype

integer

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C1947925
CD4/mm3 or percent if <5yrs or TLC
Beschrijving

CD4/mm3 or percent if <5yrs or TLC

Datatype

text

Maateenheden
  • mm³/%
Alias
UMLS CUI [1]
C0003323
mm³/%
Hemoglobine
Beschrijving

Hemoglobine

Datatype

float

Alias
UMLS CUI [1]
C0518015
ALT/AST
Beschrijving

ALT/AST

Datatype

float

Alias
UMLS CUI [1,1]
C0201836
UMLS CUI [1,2]
C0201899
Next visit date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Please select if one of the below applies
Beschrijving

Patient status

Datatype

text

Alias
UMLS CUI [1]
C0449437
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Similar models

HIV Care/ART Follow up

1 Formulieren
  1. StudyEvent: ODM
    1. HIV Care/ART Follow up
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Demographics
Facility name
Item
Facility name
text
C0018704 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
Patient card number
Item
Patient card number
integer
C0030705 (UMLS CUI [1,1])
C1549704 (UMLS CUI [1,2])
ART unique number
Item
ART unique number
integer
C1963724 (UMLS CUI [1,1])
C2735568 (UMLS CUI [1,2])
Tuberculosis Card number
Item
Tuberculosis Card number
integer
C0041296 (UMLS CUI [1,1])
C1549704 (UMLS CUI [1,2])
PMTCT Confidentiality Code
Item
PMTCT Confidentiality Code
integer
C3845698 (UMLS CUI [1,1])
C1547595 (UMLS CUI [1,2])
Patient Name
Item
Patient´s Name
text
C1299487 (UMLS CUI [1])
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Item
Gender
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
male (1)
CL Item
female (2)
Height
Item
Body height
float
C0005890 (UMLS CUI [1])
Patient address
Item
Patient address: Region
text
C0421449 (UMLS CUI [1])
Patient address
Item
Patient address: Wereda/Subcity
text
C0421449 (UMLS CUI [1])
Patient address
Item
Patient address: Kebele
text
C0421449 (UMLS CUI [1])
Patient address
Item
Patient address: House number
integer
C0421449 (UMLS CUI [1])
Telephone
Item
Telephone number
integer
C1515258 (UMLS CUI [1])
Date HIV positivity confirmed
Item
Date HIV positivity confirmed
date
C0011008 (UMLS CUI [1,1])
C0019699 (UMLS CUI [1,2])
C0750484 (UMLS CUI [1,3])
Item
HIV Test Type
integer
C0459958 (UMLS CUI [1,1])
C0449570 (UMLS CUI [1,2])
HIV Test Type
Code List
HIV Test Type
CL Item
Rapid HIV Tests (1)
CL Item
ELISA (2)
CL Item
PCR (in children) (3)
Eligibility Date
Item
Eligibility Date
date
C1976613 (UMLS CUI [1])
Item
Why eligible? Please select
integer
C0013893 (UMLS CUI [1])
Eligibility criteria
Code List
Why eligible? Please select
CL Item
Clinical only (1)
CL Item
CD4 (2)
CL Item
TLC (3)
CL Item
Transfer In (TI) (4)
Date eligible and ready
Item
Please enter the date when patient is medically eligible and ready (counseled for adherence) for ART
date
C1829734 (UMLS CUI [1,1])
C0010210 (UMLS CUI [1,2])
Item Group
Follow up chart
Item
Please specify whether patient receives free ART or pays for ART
integer
C0585761 (UMLS CUI [1])
Payment status
Code List
Please specify whether patient receives free ART or pays for ART
CL Item
Pays for ART (1)
CL Item
Free ART (2)
Item
Visit Type
text
C0545082 (UMLS CUI [1])
Visit
Code List
Visit Type
CL Item
Scheduled (S)
CL Item
unscheduled (US)
Follow-Up date
Item
Follow up date
date
C3694716 (UMLS CUI [1])
Months on ART
Item
Months on ART
text
C1963724 (UMLS CUI [1,1])
C1976623 (UMLS CUI [1,2])
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Pregnancy
Item
Pregnancy
boolean
C0032961 (UMLS CUI [1])
Estimated due date
Item
If pregnant, please specify estimated due date
date
C2825543 (UMLS CUI [1])
Item
Family planning method
integer
C0700589 (UMLS CUI [1])
Contraceptive method
Code List
Family planning method
CL Item
Condome (1)
CL Item
oral contraceptive pills (2)
CL Item
injectable/implantable hormones (3)
CL Item
Diaphragm/cervical cap (4)
CL Item
Intrauterine device (5)
CL Item
Vasectomy/tubal ligation (6)
Height
Item
Height of child
float
C0005890 (UMLS CUI [1])
Head circumference
Item
Head circumference
float
C0262499 (UMLS CUI [1])
Item
Patient functional status
text
C0598463 (UMLS CUI [1])
Functional status
Code List
Patient functional status
CL Item
working (able to perform work in or out of the house,harvest,go to school,for children normal activities or play (W)
CL Item
Ambulatory (able to perform activities of daily living) (A)
CL Item
Bedridden (unable to perform activities of daily living) (B)
Item
Developmental milestones
text
C2983568 (UMLS CUI [1])
Developmental milestones
Code List
Developmental milestones
CL Item
Appropriate (A)
CL Item
Delay (D)
CL Item
Regression (R)
Item
WHO human immunodeficiency virus stage
integer
C1976611 (UMLS CUI [1])
WHO Stage
Code List
WHO human immunodeficiency virus stage
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
Item
Tuberculosis screening
integer
C0420004 (UMLS CUI [1])
Tuberculosis screening
Code List
Tuberculosis screening
CL Item
Positive  (1)
CL Item
Negative (2)
Item
Tuberculosis prophylaxis
text
C0740413 (UMLS CUI [1])
Tuberculosis prophylaxis
Code List
Tuberculosis prophylaxis
CL Item
Currently on INH prophylaxis (INH)
CL Item
Currently on DOTS (TB Rx)
Item
Tuberculosis prophylaxis:please specify months on treatment
text
C0740413 (UMLS CUI [1])
Tuberculosis prophylaxis
Code List
Tuberculosis prophylaxis:please specify months on treatment
Item
Other Infections
text
C0009450 (UMLS CUI [1])
Other infections
Code List
Other Infections
CL Item
Zoster (Z)
CL Item
Bacterial Pneumonia (BP)
CL Item
Pulmonary TB (PTB)
CL Item
Extrapulmonary TB (ETB)
CL Item
Thrush- oral/vaginal (T)
CL Item
Ulcers-mouth, genital (U)
CL Item
Diarrhea chronic (DC)
CL Item
Diarrhea acute (DA)
CL Item
Pneumocystis pneumonia (PCP)
CL Item
CNS Toxoplasmosis (CT)
CL Item
Cryptococcal Meningitis (CM)
CL Item
Other (O)
Cotrimoxazole
Item
Cotrimoxazole
boolean
C0041044 (UMLS CUI [1])
Cotrimoxazole dispensed dose
Item
Dispensed dose, please note the number of dispensed doses
integer
C0041044 (UMLS CUI [1,1])
C0805077 (UMLS CUI [1,2])
Item
Therapy adherence
text
C1321605 (UMLS CUI [1])
Adherence
Code List
Therapy adherence
CL Item
Good (G)
CL Item
Fair (F)
CL Item
Poor (P)
Item
If fair or poor therapy adherence, please specify reason
integer
C1321605 (UMLS CUI [1])
Adherence
Code List
If fair or poor therapy adherence, please specify reason
CL Item
Toxicity/side effects (1)
CL Item
Share with others (2)
CL Item
Forgot (3)
CL Item
Felt better (4)
CL Item
Too ill (5)
CL Item
Stigma,Disclosure (6)
CL Item
Drug stock out (7)
CL Item
Lost/ran out of pills (8)
CL Item
Delivery/travel problems (9)
CL Item
Inability to pay (10)
CL Item
Alcohol (11)
CL Item
Depression (12)
CL Item
Other (13)
Other Medication
Item
Any other medication dispensed
text
C0013227 (UMLS CUI [1])
Item
Antiretroviral therapy adherence
text
C1963724 (UMLS CUI [1,1])
C1321605 (UMLS CUI [1,2])
Adherence
Code List
Antiretroviral therapy adherence
CL Item
Good (G)
CL Item
Fair (F)
CL Item
Poor (P)
Item
If therapy adherence is fair or poor,please specify why
text
C1963724 (UMLS CUI [1,1])
C1321605 (UMLS CUI [1,2])
Adherence
Code List
If therapy adherence is fair or poor,please specify why
CL Item
Toxicity/side effects (1)
CL Item
Share with others (2)
CL Item
Forgot (3)
CL Item
Felt better (4)
CL Item
Too ill (5)
CL Item
Stigma,Disclosure (6)
CL Item
Drug stock out (7)
CL Item
Lost/ran out of pills (8)
CL Item
Delivery/travel problems (9)
CL Item
Inability to pay (10)
CL Item
Alcohol (11)
CL Item
Depression (12)
CL Item
Other (13)
Antiretroviral therapy Dispense code
Item
Antiretroviral therapy Dispense code
text
C1963724 (UMLS CUI [1,1])
C2735568 (UMLS CUI [1,2])
Antiretroviral therapy Dispense code
Item
Antiretroviral therapy Dispense code
text
C1963724 (UMLS CUI [1,1])
C2735568 (UMLS CUI [1,2])
Antiretroviral therapy dispensed dose
Item
Antiretroviral therapy dispensed dose
integer
C1963724 (UMLS CUI [1,1])
C0805077 (UMLS CUI [1,2])
Item
Antiretroviral therapy side effects
integer
C1963724 (UMLS CUI [1,1])
C0879626 (UMLS CUI [1,2])
Antiretroviral therapy side effects
Code List
Antiretroviral therapy side effects
CL Item
Nausea (1)
CL Item
Diarrhea (2)
CL Item
Fatigue (3)
CL Item
Headache (4)
CL Item
Numbness/Tingling (5)
CL Item
Rash (6)
CL Item
Anemia (7)
CL Item
Abdominal pain (8)
CL Item
Jaundice (9)
CL Item
Fat changes (10)
CL Item
dizzy,anxiety, night mare (11)
Item
Reason for change of treatment
integer
C1299575 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Reason for change
Code List
Reason for change of treatment
CL Item
Toxicity/side effects (1)
CL Item
Pregnancy (2)
CL Item
Risk of Pregnancy (3)
CL Item
Due to new TB (4)
CL Item
New Drug available (5)
CL Item
Drug out of stock (6)
CL Item
Other (7)
CL Item
immunologic failure (8)
CL Item
Virologic failure (9)
Item
Reason for treatment stop
integer
C0392360 (UMLS CUI [1,1])
C1947925 (UMLS CUI [1,2])
Reason for treatment stop
Code List
Reason for treatment stop
CL Item
Toxicity/side effects (1)
CL Item
Pregnancy (2)
CL Item
Treatment failure (3)
CL Item
Poor adherence (4)
CL Item
Illness,hospitalization (5)
CL Item
Drugs out of stock (6)
CL Item
Patient lacks finances (7)
CL Item
Other patient decision (8)
CL Item
Planned treatment interruption (9)
CL Item
Other (10)
CD4/mm3 or percent if <5yrs or TLC
Item
CD4/mm3 or percent if <5yrs or TLC
text
C0003323 (UMLS CUI [1])
Hemoglobine
Item
Hemoglobine
float
C0518015 (UMLS CUI [1])
ALT/AST
Item
ALT/AST
float
C0201836 (UMLS CUI [1,1])
C0201899 (UMLS CUI [1,2])
Date
Item
Next visit date
date
C0011008 (UMLS CUI [1])
Item
Please select if one of the below applies
text
C0449437 (UMLS CUI [1])
Compliance behavior
Code List
Please select if one of the below applies
CL Item
transferred out (TO)
CL Item
not seen since>/=1month<3months (Lost)
CL Item
Lost to follow up for > 3 months (Drop)
CL Item
Dead (Dead)
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