ID

16212

Description

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

Link

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

Keywords

Follow-Up Studies

7/5/16 7/5/16 -

Uploaded on

July 5, 2016

DOI

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License

Creative Commons BY-NC 3.0

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Ministry of Health, Ethiopia- HIV–Exposed Infant Follow up Card

model
Details

HIV–Exposed Infant Follow up Card

StudyEvent: ODM
1. HIV–Exposed Infant Follow up Card

Name

Type

Description | Question | Decode (Coded Value)

Data type

Alias

Item Group

Demographics

Facility name

Item

Facility name

text

C0018704 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])

Date of Enrollment

Item

Date of Enrollment

date

C2986327 (UMLS CUI [1])

Medical record number

Item

Infants Medical record number

text

C1301894 (UMLS CUI [1])

Patient Identifier

Item

Unique "HIV exposed infant- HEI" ID

text

C0030705 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])

Referral

Item

Infant referred from

text

C0034927 (UMLS CUI [1])

Name

Item

Name of Infant

text

C0027365 (UMLS CUI [1])

Date of birth

Item

Date of birth

date

C0421451 (UMLS CUI [1])

Place of birth

Item

Place of birth

text

C0032040 (UMLS CUI [1])

Age

Item

Age at enrollment

integer

C0001779 (UMLS CUI [1])

Mothers name/caretakers name

Item

Mothers name/caretakers name

text

C0802060 (UMLS CUI [1])
C0085537 (UMLS CUI [2,1])
C0027365 (UMLS CUI [2,2])

Mothers MRN

Item

Mothers MRN

text

C1301894 (UMLS CUI [1])

Caregiver

Item

If "Caretaker" describe relationship

text

C0085537 (UMLS CUI [1])

Address

Item

Address:Region

text

C0421449 (UMLS CUI [1])

Address

Item

Address: Subcity

text

C0421449 (UMLS CUI [1])

Address

Item

Address: Kebelle

text

C0421449 (UMLS CUI [1])

Address

Item

Address: House number

integer

C0421449 (UMLS CUI [1])

Phone number

Item

Patient contact: phone number

integer

C1515258 (UMLS CUI [1])

Item

Mothers status

integer

C2029853 (UMLS CUI [1])

Code List

Mothers status

CL Item

Alive (1)

CL Item

Dead (2)

Item

Mothers status: if alive

integer

C2029853 (UMLS CUI [1])

Code List

Mothers status: if alive

CL Item

enrolled in HIV/ART care (1)

CL Item

Not enrolled in HIV/ART care (2)

Item

Mothers status: if enrolled in HIV/ART care

integer

C2029853 (UMLS CUI [1])

Code List

Mothers status: if enrolled in HIV/ART care

CL Item

Within the facility (1)

CL Item

Out of the facility (specify) (2)

Mothers status

Item

Mothers status: specify facility

text

C2029853 (UMLS CUI [1])

PMTCT intervention

Item

Mothers PMTCT intervention

integer

C3845698 (UMLS CUI [1,1])
C1273869 (UMLS CUI [1,2])

PMTCT intervention

Code List

Mothers PMTCT intervention

CL Item

None (1)

CL Item

sdNVP (2)

CL Item

AZT + sdNVP + 3TC (3)

CL Item

Other:(specify regimen & duration) (4)

PMTCT intervention

Item

Mothers PMTCT intervention:specify other regimen & duration

text

C3845698 (UMLS CUI [1,1])
C1273869 (UMLS CUI [1,2])

Antiretroviral prophylaxis

Item

Infant Antiretroviral prophylaxis

integer

C0599685 (UMLS CUI [1,1])
C0199176 (UMLS CUI [1,2])

Antiretroviral prophylaxis

Code List

Infant Antiretroviral prophylaxis

CL Item

None (1)

CL Item

SdNVP (2)

CL Item

SdNVP+AZT for 7days (3)

CL Item

Other specify (Regimen & duration) (4)

Antiretroviral prophylaxis

Item

Infant Antiretroviral prophylaxis: specify other Regimen & duration

text

C0599685 (UMLS CUI [1,1])
C0199176 (UMLS CUI [1,2])

Antiretroviral prophylaxis

Code List

Infant Antiretroviral prophylaxis: specify other Regimen & duration

Item

Fathers HIV Status

integer

C0458074 (UMLS CUI [1])

Code List

Fathers HIV Status

CL Item

Positive (1)

CL Item

Negative (2)

CL Item

Unknown (3)

Item

Father status

integer

C2029840 (UMLS CUI [1])

Code List

Father status

CL Item

Alive (1)

CL Item

Dead (2)

Item

Father status:if alive

integer

C2029840 (UMLS CUI [1])

Code List

Father status:if alive

CL Item

enrolled in HIV/ART care (1)

CL Item

Not enrolled in HIV/ART care (2)

Item

Father status:if on ART, specify ART number

integer

C2029840 (UMLS CUI [1])

Code List

Father status:if on ART, specify ART number

Immunizations

Item

Immunizations:BCG

boolean

C0020971 (UMLS CUI [1])

Item

Immunizations:OPV

integer

C0020971 (UMLS CUI [1])

Code List

Immunizations:OPV

CL Item

1 (1)

CL Item

2 (2)

CL Item

3 (3)

Item

Immunizations:DPT or Pentavalent

integer

C0020971 (UMLS CUI [1])

Code List

Immunizations:DPT or Pentavalent

CL Item

1 (1)

CL Item

2 (2)

CL Item

3 (3)

Immunizations

Item

Immunizations:Measles

boolean

C0020971 (UMLS CUI [1])

Follow up chart

Item Group

Follow up chart

Visit date

Item

Date of visit

date

C1320303 (UMLS CUI [1])

Age

Item

Age

integer

C0001779 (UMLS CUI [1])

Weight

Item

Weight

float

C0005910 (UMLS CUI [1])

Length

Item

Infant length

integer

C1444754 (UMLS CUI [1])

Head circumference

Item

Head circumference

float

C0262499 (UMLS CUI [1])

Item

Growth pattern

integer

C1156245 (UMLS CUI [1])

Code List

Growth pattern

CL Item

normal (1)

CL Item

if there is growth failure (2)

Developmental milestones

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)

Feeding practice

Item

Infant Feeding practice

integer

C0420979 (UMLS CUI [1])

Feeding practice

Code List

Infant Feeding practice

CL Item

Infant is on exclusive breastfeeding (1)

CL Item

Infant is on exclusive replacement feeding (2)

CL Item

Infant is on mixed feeding (3)

CL Item

Infant is on breastfeeding and complementar (4)

Breast condition

Item

Breast condition

integer

C1623040 (UMLS CUI [1,1])
C0348080 (UMLS CUI [1,2])

Breast condition

Code List

Breast condition

CL Item

1 (1)

CL Item

2 (2)

CL Item

3 (3)

CL Item

4 (4)

Item

Abnormal findings or diagnosis that may suggest HIV infection

integer

C1704258 (UMLS CUI [1])

Code List

Abnormal findings or diagnosis that may suggest HIV infection

CL Item

none (0)

CL Item

Generalized lymphadenopathy (1)

CL Item

Oral Candidiasis (2)

CL Item

Purulent ear discharge (3)

CL Item

Findings suggestive of pneumonia or lower respiratory tract infections (4)

CL Item

Persistent diarrhea (5)

CL Item

Hepatosplenomegaly (6)

CL Item

Severe skin lesions (7)

CL Item

Persisten (8)

Treatment/medication

Item

Treatment/medication given

text

C0013216 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])

Cotrimoxazole prophylaxis

Item

Cotrimoxazole prophylaxis:dose

integer

C0041044 (UMLS CUI [1,1])
C0199176 (UMLS CUI [1,2])

Cotrimoxazole prophylaxis

Item

Cotrimoxazole prophylaxis: Adherence

integer

C0041044 (UMLS CUI [1,1])
C0199176 (UMLS CUI [1,2])

Cotrimoxazole prophylaxis

Code List

Cotrimoxazole prophylaxis: Adherence

CL Item

Good (1)

CL Item

Fair (2)

CL Item

Poor (3)

Item

HIV test done?

integer

C1321876 (UMLS CUI [1])

Code List

HIV test done?

CL Item

Sample collected for DNA PCR (1)

CL Item

Sample collected for DNA PCR (1)

CL Item

DNA/PCR result negative (2)

CL Item

DNA/PCR result Positive (3)

CL Item

Rapid antibodytest result negative (4)

CL Item

Rapid antibodytest result positive (5)

CL Item

DNA/PCR test result inditerminate (6)

CL Item

No test done (0)

Conclusion & Decision

Item

Conclusion & Decision

integer

C1707478 (UMLS CUI [1])
C0679006 (UMLS CUI [2])

Conclusion & Decision

Code List

Conclusion & Decision

CL Item

Infant has no clinical or laboratory evidence of HIV infection currently but needs follow up (0)

CL Item

Infant has clinical evidence of HIV infection and is referred for Pediatric HIV/ART care with in the facility (1)

CL Item

Infant has lab evidence of HIV infection and referred to pediatric HIV/ART care with in the facility (2)

CL Item

infant has clincial and laboratory evidence of HIV infection and referred for pediatric HIV care/ART with in the facility (3)

CL Item

Infant has clinical evidence of HIV infection and is referred for Pediatric HIVcare/ART outside the facility (4)

CL Item

Infant has laboratory evidence of HIV infection and is referred for Pediatric HIV care/ART outside the facility (5)

CL Item

Infant has clinical and laboratory evidence of HIV infection and referred for Pediatric HIV care/ART outside the facility (6)

CL Item

Infant is confirmed not to have clinical and lab evidence of HIV infection and discharged from follow up (7)

CL Item

Any Other conclusion Specify (Including Death & lost to follow up) (8)

Conclusion & Decision

Item

Conclusion & Decision: Specify Any Other conclusion (Including Death & lost to follow up)

text

C1707478 (UMLS CUI [1])
C0679006 (UMLS CUI [2])

Discharged, Name of Health Care provider

Item

Name of Health Care provider who referred or discharged the Infant from follow up

text

C0586514 (UMLS CUI [1,1])
C2361125 (UMLS CUI [1,2])

Discharged, Signature of Health Care provider

Item

Signature of Health Care provider who referred or discharged the Infant from follow up

text

C0586514 (UMLS CUI [1,1])
C0807938 (UMLS CUI [1,2])

Date of discharge

Item

Date of discharge

date

C2361123 (UMLS CUI [1])

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