Download General_Oncology_Initial_Form_v1

Oncology
GENERAL
Initial Encounter Form v1.0
First Name:
patient.given_name
Date:
encounter.encounter_datetime
Middle Name:
patient.middle_name
Last Name:
patient.last_name
AMRS ID:
patient_identifier_type_id=8
Date of Birth: patient.birthdate
If Birth-date Unknown, Age: patient.birthdate_estimated
Sex: □M □F
person.gender
Tribe spoken at home:
patient.tribe
County:person_address.state_county
NHIF6266 [] Yes6815 []
No1107________
Clinic Site: encounter.location_id
□MTRH □Chulaimbo□Busia□Webuye□Kitale□ Other (specify):
Client Phone Number _______person_attribute_type_id=17
SOCIAL HISTORY
From where were you referred to our clinic?(6749)
□ MTRH Staff(1274)□ Non-MTRH Staff(6479)□ Self-Referral(978)
What is the reason for your current visit?(1834)
□ Scheduled Clinic (1246)□Symptoms (1068)
Chief Complaint:8916 (5219)
□ Feeling well (5006) □ Having symptoms(1068) [ ] Other5622___1915(specify)
How long did it take to travel to clinic today?(5605)
□ Less than 30 minutes(1049)□ Between 30 and 60 minutes(1050)□ Between 1 and 2 hours(1051)□ Between 2 and 4 hours(6412)
□ Between 4 and 8 hours(6413)□ More than 8 hours (6414)
What was the primary mode of transportation to the clinic?(6468)
□Walking(6415)□Matatu(6416)□Boda-Boda(6580)□ Bus(6469)□ Taxi(6470)□ Private vehicle(6471)
What is Your Main Occupation?(1972)
□Housewife/Husband(1969)□Farmer(1967)□Casual Laborer(1966)□Civil Servant(8407)□Education Professional(1968)
□Health Professional(5619)□Other(5622)
What is Your Average amount of income per month (Kshs)?(7003)
□Less than 1000 KSH(7002) □1001 to 2000 KSH(6316) □2001 to 3000 KSH(6314) □3001 to 5000(6315)□5001 to 10000(6316)
□More than 100000(6317)
How many people usually live in your household or are staying with you now? (6801)_____________
Level of Patient Education (1605)
□Primary (6214) □Secondary (6215)
□ Tertiary(1604)
□No Formal Education(1107)
What is your current marital status?(1054)
□ Not Applicable(1175)□Single(1057)□ Married (monogamous)(5555)□ Married (polygamous)(6290)□ Living with a partner(1060)
□Separated(1056)□ Divorced(1058)□ Widowed(1059)
What method of family planning do you currently use? (Select all that apply) (374)
□ Condoms (190) □ Sterilization/Hysterectomy (5276) □ Intrauterine Device (5275)
□ Diaphragm/Cervical Cap (5278)
□ Oral Contraceptive Pills (5274) □ Natural Family Planning/Rhythm (5277) □ Injectable Hormones (5279) □ Don’t Know (1642)
□ None (1107)□ Other (5622) Specific _____________
OncologyGeneral Initial Encounter Form v1.0
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Are you currently breastfeeding an infant?(2056)
□ Yes (1065)
□ No (1066)
Do you presently, or have you in the past smoked cigarettes? (6473) o Yes (1065) o No (1066)
Do you drink alcohol? (1684) □Yes(1065) □ No(1066)
Have you ever drunk alcohol?(6474) □ Yes(1065) □ No(1066)
PAST MEDICAL HISTORY
Are you currently being treated for any of the following illnesses? (6245)
□ HIV /AIDS (884)□ Cardiovascular diseases (7971)
□ Cancer (6483)□Febrileillness (7385)□Other______________(Specify)(5622)
What Medication Allergies Do You Have?
□6011 Penicillin□6012Sulfa□2088Other1083 (specify)____2089______□ None1107
Are you currently taking any of the following medications?(6789)
□ Antibiotics (1195) □ Chemotherapy(6575) □ Opioid Analgesics (8408)□Non-Opioid Analgesics (8409)□ Anticoagulants
(8410)□Vitamins (6339)□ Anti-Retrovirals(1085) □Antihypertensives(1635)□ Anticonvulsants (6778) □Anti TB (6176)
□ Other: (5622)…………………..(specify)
Please list all your past surgeries9217 (6478)
…1915……………………………………………………………………………….
HOSPITALIZATION DETAILS (1852)
Have you been hospitalized since last visit? (976) □Yes(1065) □ No(1066)
Hospitalization Location (1273)
Hospitalization Diagnosis (1929)
Details of Hospitalization (1915)
No. of febrile illnesses since last clinic visit: ___(
8411)
No. of packed red blood cells transfused since last clinic visit: ___9216
CHEMOTHERAPY:
Please list all chemotherapy medication details since last visit (8786)
Drug Name:(1895)
Reason for Use:9222 1915
Date Started1190
Date Stopped: (1191)
Dose (mg): 1899
Frequency: 1896
Reason for Stop / Change:8414
Drug
Name1895
Reason for
Use922219
15
Date
Started1
190
Date
Stopped
1191
Dose
(mg)
1899
Frequency
1896
Reason for Stop / Change:8414
□ TOXICITY (1879) □COMPLETED (1267) □PATIENT
REFUSAL (1504) □REGIMEN FAILURE (843)□HEALTH
ISSUES (1548)□OTHER NON-CODED (5622)
□ TOXICITY (1879) □COMPLETED (1267) □PATIENT
REFUSAL (1504) □REGIMEN FAILURE (843)□HEALTH
ISSUES (1548)□OTHER NON-CODED (5622)
REVIEW OF SYSTEMS
General: (1069)□ No Complaints(664) □ Fevers (5945)□ Pain(6613) □ Fatigue(5949) □ Jaundice(215) □ Weight Loss(832)
□ Night Sweats(6029)
Self reported pain score (7080): (0-10) Notes:_7032
Where is the location of your pain? (8415)_________________________________________
HEENT: (1070)□ No Complaints(664) □ Hearing Difficulties(861) □ Swallowing Difficulties(5954) □ Vision Difficulties(5953)
Notes:
OncologyGeneral Initial Encounter Form v1.0
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Cardiopulmonary: (1071)
□NoComplaints (664)
□Cough107 (5959-duration)□ days (1072) □weeks(1073) □ months(1074) –
Quality of cough 5958 □ blood(1077) □ white(1075) □purulent(1076) □ other(5622)
□SOB5960(5962-duration)□days(1072)□ weeks(1073) □ months(1074) - □ at rest(5961) □ on exertion(5963)
□Chest Pain139 (5971)
□ Days(1072) □ Weeks (1073) □ Months(1074)
Location (5976) □Sub Sternal(5973) □Right(5141) □Left (5139) □Posterior(541)
Notes:
Gastrointestinal: (1078) □ No Complaints (664)
□Dysphagia(881) □ days (6719, 1072) □ weeks(6719, 1073) □ months(1074)
□ Jaundice (215) □days(6720, 1072) □ weeks(6720, 1073) □ months(6720, 1074)
□ Lack of Appetite (6031)□ days(6721,1072) □ weeks(6721, 1073) □ months(6721, 1074)
□Constipation(996)
□Diarrhea(16)
□Melena(6494)
□ Bleeding per Rectum(6495)
□ Abdominal pain(151) □ days(2007, 1072) □ weeks(2007, 1073) □ months(2007, 1074)
Location (1884 )□ RUQ(5107) □ RLQ(1882) □ LUQ(1883) □ LLQ (5104)□Epigastric(5099)
□Suprapubic(575)
Genitourinary: (1080)
□ No Complaints (664)□Dysuria (6020)
Volume (6021)
□Increased Urine Volume (8417)□Increased Urine Urgency(8418)□Reduced Urine
If Female, LMP ___/____/________ (1836)
Musculoskeletal: (1081)
□ No Complaints (664)□ Edema of Legs(590)□Leg Ulcers(951)
□Pain(6034) (8591-duration)□ Days (1072) □ Weeks (1073) □ Months(1074)
Location (6696) □Neck(6598) □ RUE(1233) □ LUE(1232) □ RLE(1235) □ LLE(1234) □Back (6601)
□Chest(1349) □ Buttocks(6597)
Notes:
PHYSICAL EXAMINATION
Vitals: (1114) Systolic Blood Pressure / Diastolic Blood Pressure (5085/5086) /
Pulse(5087) beats/min
(5242) Temperature [o C] (5088)
Weight (5089)kg
Height (5090) cm
BSA (980)
Blood Oxygen Saturation (…………%) (5092)
Breathing Rate
m2
ECOG Performance Index: (6584)
□ 0 (normal activity) (1115) □ 1 (Symptomatic but ambulatory) (6585) □ 2 (Debilitated, but bedridden < 50% of day)(6586)
3 (Debilitated, bedridden >50% of the day) (6587) □ 4 (100% Bedridden) (6588)
□
General Exam:8419(1119)□ Not Done(1118) □ Normal (1115) □ Temporal Wasting (5201) □ Pallor (5245) Comments: 1915
HEENT: (1122)
□ Not Done (1118) □Normal (1115)
Eyes: □ Scleral Icterus(5192)□ Pale Conjunctiva(516)
Neck: □ Deviated Trachea(513)□ Nuchal Rigidity(5170)
Mouth □Thrush(5334)□ Other lesions(6672)
Chest: (1123)
OncologyGeneral Initial Encounter Form v1.0
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□ Not Done (1118) □Normal (1115) □ Dullness to percussion(5138) □ Breath Sounds Diminished(5115)
□ Bronchial Breath Sounds(5116) □ Rhonchi/Wheezes(5181) □Crepitations(5127)
Heart: (1124)
□ Not Done (1118)
□Normal(1115)
□ Evidence for Enlargement(5158) □ RV Lift(5157) □ LV Lift(5156)
□ Abnormal Sounds(1117) □ S3(550) □ Pericardial Rub(5176) □ Murmurs(562) □ Systolic Ejection(5166) □Holosystolic(5162)
□ Diastolic Descrescendo (5160) □ Diastolic Rumble(5164)
Abdomen: (1125)
□ Not Done (1118) □Normal (1115) □Mass(5103) □ Ascites(581)
□Hepatomegaly(5008)cm below costal margin (5153)
□Splenomegaly(5009)cm below costal margin (5195)
□ Tender to Palpation (5105)
Abdominal Tenderness Location (1884) □RUQ(5107)
□Suprapubic(575)
□ RLQ (1882) □ LUQ (1883)
□ LLQ (5104) □Epigastric(5099)
Urogenital: (1126) □ Not Done (1118) □ Normal (1115) □ Abnormal(1116)
If Male, Testicular Exam8420
□Not Done(1118)
□Normal(1115)
□Abnormal(1116)
□ Not applicable (1175)
Extremities : (1127)
□ Not Done (1118) □Normal (1115)□ Edema (590) □ Leg Ulcers(951) □ Cellulitis(134)
Mass(582)
□ Kaposi's sarcoma(507) □
LYMPH NODE EXAM FINDINGS (1121)
□ Not Done (1118) □Normal (1115) □ Submandibular(504) □ Supraclavicular(505) □ Cervical(643) □ Axillary (5112) □ Inguinal
(506)
□ Generalized Lympadenopathy (8261) □ Other (5622)□ Normal (1115) □ Not Done (1118)
SKIN EXAM FINDINGS (1120) (SKIN EXAM FINDINGS, DETAILED (8272); LATERALITY, BODY PART,),
MEASUREMENT 1, MEASUREMENT 2
Please enter details of each skin exam finding:
SKIN EXAM FINDING:(1120)
o Not Done (1118) o Normal (1115)o Mass (528)o Abnormally warm (8188)
Body Part with this skin finding: (8265)
o Face(6599) o Neck(6598)o Arm (1237) o Leg(1236)o Chest(1349) o Back(6601) o Abdomen (1350) o Genitals(6600) o Buttocks
(6597)
Side of body with skin finding 8264
oRight (5141)o Left (5139)o Not applicable
Measurement (bi-directional) _____8270cm X _____8271cm
Musculoskeletal: (1128)
□ Not Done (1118)
□ Normal (1115)
□ Abnormal (1116) comments……………
Neurologic: (1129)
□ Not Done (1118) □Normal (1115) □ Cranial Nerve Abnormality(599) □ Decreased Sensation(497) □ Abnormal Gait(5108)
LAB RESULTS:
OncologyGeneral Initial Encounter Form v1.0
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Complete Blood Count
□ Hematocrit (1015) ____ %
Test Date ___
□ Hemoglobin (21)____g/dL
Test Date _____
□ Mean corpuscular volume (851)___fL
□ Platelets count (729)___10^3/µL
□ Serum white blood cells count (678)___10^3/µL
□ Absolute neutrophil count, automated (1330)_10^3/µL
□Retic count (1327) %
Chemistry
□ Serum uric acid test (6134) __ mg/dL
□ Serum creatinine (790)____ µmol/L
□ Serum electrolytes (5473)
□Serum bicarbonate (1135)___ mmol/L
□Serum chloride (1134)____ mmol/L
□Serum potassium (1133)__ mmol/L
□Serum sodium (1132)_____ mmol/L
Hepatic Function
□Serum glutamic-pyruvic transaminase (654)____ U/L
□Serum glutamic-oxaloacetic transaminase (653)___
Urinalysis(302)
□urinalysis, microscopic )___
□presence of pus cells, urine (1984)___
□presence of red blood cells, urine (1985)__
□presence of protein, urine (2339)
□presence of sugar, urine (2340)
U/L
□Serum alkaline phosphatase (785)____ U/L
□Serum direct bilirubin (1297)____ µmol/L
□Serum total bilirubin (655)____ µmol/L
□Serum total protein (717)____ g/L
IMAGING RESULTS(6500)
Echo Study (1536) Test date___/___/_____ (use obs.datetime for all test dates)
□ Normal (1115) □ Abnormal (1116) □ Left Ventricular Hypertrophy (1532)
□ Right Ventricular Hypertrophy (1533)□ Cardiac Arrhythmia (1530)
□ Atrial Fibrillation (1531) □ Other Non-Coded (5622) ___Specify
Chest X-RayTest date___/___/_____
Reported by :
Results :
Radiologist 2395
Code : 0=normal1115 1=PI
Effusion1136 2=Infiltrate6049
3=milliary1137
5=cavitary6052 4=Diffuse
abn/non-milliary6050 6 =
Cardiomegaly5158 7=other
abnormality5622
Clinical Officer 12
Code : 0=normal1115 1=PI
Effusion1136 2=Infiltrate6049
3=milliary1137
5=cavitary6052 4=Diffuse
abn/non-milliary6050 6 =
Cardiomegaly5158 7=other
abnormality5622
Patient 7178
Code : 0=normal1115 1=PI
Effusion1136 2=Infiltrate6049
3=milliary1137
5=cavitary6052 4=Diffuse
abn/non-milliary6050 6 =
Cardiomegaly5158 7=other
abnormality5622
X-Ray Type: 6897 ______ Result _____ Date __/___/___
X-RAY, SHOULDER 394X-RAY, PELVIS 392X-RAY, ABDOMEN 101X-RAY, OTHER 309X-RAY, SKULL 386X-RAY, LEG
380X-RAY, HAND 382X-RAY, FOOT 384X-RAY, ARM 377
X-RAY, SPINE 390X-Ray, Chest12BARIUM SWALLOW (Esophagus X-ray) 1513
BARIUM MEAL 1512 (Upper GI, X-ray)
CT Head (846) Test date___/___/_____
□Normal (1115) □ Abnormal (1116)
CT Abdomen (7114) Test date___/___/_____
□Normal (1115) □ Abnormal (1116)
CT Chest 7113) Test date___/___/_____
□Normal (1115) □ Abnormal (1116)
Ultra Sound –
ULTRASOUND, RENAL: □ Patient reported (7188) □ Radiologist reported(7115)Test date___/___/_____
ULTRASOUND, HEPATIC□ Patient reported (7186) □ Radiologist reported(852)Test date___/___/_____
OBSTETRIC ULTRASOUND□ Patient reported (9221) □ Radiologist reported(6221)Test date___/___/_____
ULTRASOUND, ABDOMEN□ Patient reported (7183) □ Radiologist reported(845) Test date___/___/_____
Other Tests (Radiology)8190
DIAGNOSIS
How was Diagnosis Established? (7193, 6504)
OncologyGeneral Initial Encounter Form v1.0
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□ Prior Clinical Records(6505) □ Review of Laboratory Finding(6506) □ Clinically (6507) □ Peripheral Blood Film(6508)
□ Biopsy (7189)
Diagnosis Date
/
/
(use obs.datetime)
How was the biopsy specimen collected? (7193, 6509)
□FNA(7190) □ Core Needle(6510) □ Excisional/Surgical(6511)□ Skin Punch(6512) □ Bone Marrow(6513)
Pathological Diagnosis of Specimen (7193, 8278):
Is Biopsy Consistent With Clinical Suspicion?(7193, 6605) □ Yes (1065) □ No (1066)
CANCER DIAGNOSIS, DETAILED (7177) – (This will be a repeating concept) this is for all cancer diagnoses below. For all stages
PROBLEM ADDED (6042) – specific to the cancer below
SARCOMA
□ Kaposi's Sarcoma(507)□ Soft Tissue Sarcoma(6486) □Osteogenic Sarcoma(6487)□ Ewing's Sarcoma(6488)
□Rhabdomyosarcoma(6489)□ Other Sarcoma___(6490)______
GU CANCER
□ Bladder (6515)□ Renal Cell (6516)□Penile Cancer8421□Wilm's(6517)□ Prostate(6518)□ Testes(6519)□ GU Cancer,
NOS(6514)
HEAD AND NECK
□ Thyroid Cancer(6529)□ Squamous Cell, Nasopharynx(6530)□ Squamous Cell, Oropharynx(6531)□ Squamous Cell,
Hypopharynx(6532)□ Squamous Cell, Laryngeal(6533)□ Squamous Cell, NOS7421□ Posterior Nasal Space(6535)□ Head & Neck
Cancer, NOS (6528)
GYNECOLOGIC CANCER
□ Cervical Cancer(6537)□Choriocarcinoma8422□ Ovarian Cancer(6539)□Endometrial / Uterine Cancer (
Gynecological Cancer, NOS(6536)
6538)□
LYMPHOMA
□ Non-Hodgkin's(6553)□ Hodgkin's(6552)□ Burkitt’s8423□ Lymphoma, NOS(6551)
SKIN CANCER
□ Squamous Cell(6541)□ Basal Cell(6542) Melanoma(6543)□ Skin Cancer, NOS (6540)
GI CANCER
□ Esophageal Cancer(6521) □ Gastric Cancer(6522)□ Pancreatic Cancer(6523)□Cholangiocarcinoma(6524) □ Colon Cancer(6525)
□ Rectal Cancer(6526) □ Anal Cancer(6527) □ Hepatocellular Carcinoma (HCC) (6568) □ Gastro-Intestinal Cancer, NOS (6520)
OTHER
□Retinoblastoma8424□Neuroblastoma8425□MultipleMyeloma(6555)□Other Solid Cancer, NOS (6668)□ Other liquid cancer (6554)
METHOD OF STAGING (6558)
CANCER STAGE (6582)
□ Not Applicable(1175) □ Unknown(1067)□ Limited (6563)□ Extensive (6564) □ Metastatic (6565)
CANCER GRADE8426
[] Low6848 [] High6927
HAEMATOLOGICAL / NON-CANCER
LEUKEMIA
□ChronicMyelogenous Leukemia (CML) (6547)□ Chronic Lymphocytic Leukemia (CLL) (6548)
□AcuteMyelogenous Leukemia (ALL) (6549)□ Acute Lymphocytic Leukemia (ALL)(6550)
□ Leukemia, NOS (216)
OncologyGeneral Initial Encounter Form v1.0
6
ANEAMIA
□ Iron Deficiency Anemia(1226)□ Aplastic Anemia(6556)□ Hemolytic Anemia (2)□ TTP/HUS(6557)□ Other(5622)
PLAN:
TESTS ORDERED
What tests will be ordered for the patient? (1271) □None (1107)
□ Complete Blood Count (1019) □ SGPT/ALT (654) □ SGOT / AST (653) □Creatinine (790) □CT Scan (6501) □ Chest X-ray (12) □
Ultrasound(6502) □Echo (1536) □ Other5622 (specify):1915
TREATMENT PLAN:
Pre-TreatmentBSA:(computeusingHeight&Weight) (980) =SQRT(HEIGHT2/WEIGHT) height in meters& weight in Kgs
Treatment Plan:8723 [ ] Chemotherapy (6575) [ ] Radiation Therapy8427 [ ] Surgery7465
Reason for Surgery:8725 [ ] Diagnosis8727 [ ] Curative8428 [ ] Palliative8724
7480
Surgical Procedure: (7479)
Location:8265, 8268
Findings1915:
CHEMOTHERAPY:
8723[] Start1256[ ] Change Regimen1259 [] Stop Regimen1260 [] Continue Regimen1257
If Start Regimen:8726
Drug Name:1895
Chemotherapy Regimen: 6574
Chemotherapy intent2206: □ Curative8428 □Adjuvantor9218□Neo adjuvant9219 □Disease or Symptom control9220
Cycle Number:6643
Start Date (1190):
Route7463: [ ] po7447 [] IV7458
Dose (mg)1899 – this can be calculated based on Body surface area, and dose mg/m2 and dose reduction
If Change Regimen:8726
- Pick from list of existing drugs from patient reported1895
- Enter Dose Reduction % - calculate new dose1899
- Chemotherapy intent: □ Curative8428 □Adjuvantor9218□Neo adjuvant9219 □Disease or Symptom control9220
- Cycle Number:6643
- Start Date (1190):
- Route7463: [ ] po7447 [] IV7458
- Dose Reduction (mg): (enter) – this can be calculated based on Body surface area, and dose mg/m2 and dose reduction
- Reason for change8414:□ Toxicity (1879) □Completed(1267) □Patient Refusal(1504) □Regimen Failure (843)□Health
Issues(1548)□Other(5622)
If Stop Regimen:
- Reason for Stop8414□ Completion1267 □ Toxicity1879 □Progression843
Non- Chemotherapy Agents / Additional Drugs – model like MEDICATIONS ADDED – include start date etc
ADDITIONAL THERAPIES PLANNED
Referrals (check all that apply)1932 (1272)
□None(1107) □ Hospice/Palliative(6569) □ Surgery(6571) □ AMPATH CENTER(7775) □ Radiology(6572) □ Pathology(6573)
□Radiation Therapy (6570)□Physiotherapy(1905) □ Other(5622) Specify ____1915______________
General Notes:……..
Provider1#: (encounterProvider)
Clinic Return Date5096: _______
OncologyGeneral Initial Encounter Form v1.0
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OncologyGeneral Initial Encounter Form v1.0
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