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ADULT CLINICAL SUMMARY v3.5

Date Implemented: Apr-9-2010

Sample Summary:Adult Clinical Summary v3.5.pdf

The components of this version of the adult summary are outlined below:

•    Patient Name, AMPATH IDs (includes primary IDs and all other IDs), Gender, DOB (Age: years and months)

•    First encounter date

•    Highest WHO Stage - looks at all previous WHO Stages for a patient and gives the highest one (insert derived concept link here)

•    6 Months HIV Rx Adherence - gives results for patient HIV medication adherence for the six month duration from the data of clinical summary generation.  Response include: ...... (insert derived concept link here)

•    Problem List - for now, we go into all previous encounters and bring up all problems that have ever been documented for the patient.  This is suboptimal.  We are encouraging providers to remove all problems that have been resolved by entering them on encounter forms.  In the summary we state 'Remove Resolved Problems through Encounter Form'((insert derived concept link here)

•   Recent ARVs and OI Meds - Lists all current meds and Opportunistic Infection Medications for the patient - based on information from the last encounter form (i.e. prescription info)(insert derived concept link here)

•    Flowsheet - Components include Weight, HgB, CD4, Viral Load, SGPT and Creatinine

Our algorithm for flowsheet components only takes the earliest observation and then the latest four observations for the relevant item.  We have dates when each component was recorded or ordered on the encounter form.

If there is a result but we do not see an order on the encounter form, we state 'No Order'.  If on the other hand, an order exists but there is no result, we state 'Test Ordered'

•   Last 2 Chest Xrays - Gives results of the last two chest xrays for the patient

•    Reminders:

The reminders implemented in v3.5 include:

  1. Baseline CXR
  2. Baseline CD4
  3. Baseline SGPT
  4. Baseline Creatinine
  5. Baseline Hemoglobin
  6. WHO Stage

- For each reminder, providers are asked to check the action taken:

Actions include:
1-Ordered Today, 2-Not Applicable, 3-Previously Ordered, 4-Pt Allergic, 5-Pt Refused, 6-I Disagree with Reminder, 7-Other(Explain)

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