Adult & Pediatric HIV/AIDS Clinical System

PATIENT DATA
Demographics	Patient name	Date updated		Patient phone number	Patient address
	Patient fax number	Gender		Race	Patient status (active, inactive, etc.)
	Date of birth	Caretaker's name		Patient occupation	Pets in household
	Education achieved	Social Security Number		Marital status	Patient E-mail address
	Primary physician name	Referring physician name		Employer name, address, and phone number
	Closest relative name, address, relationship, and phone number			Date patient discharged, transferred, deceased
Social Habits	Date updated		Date Tested Positive	Birth Control Method		Source of HIV Infection
	Date last TB Test		TB Test Status (Pos/Neg)	Treatment if Negative TB Test		Syphilis?
	Syphilis Year		Gonorrhea?	Gonorrhea Year		Genital Herpes?
	Genital Herpes Year		Chlamydia	Chlamydia Year		Trichomonas
	Trichomonas Year		Venereal Warts	Venereal Warts Year		Hepatitis A
	Hepatitis A Year		Hepatitis B	Hepatitis B Year		Hepatitis C
	Hepatitis C Year		Hepatitis D	Hepatitis D Year		Gravita
	Parity		Age at Menarche	Age at First Birth		Age at Menopause
	Date Last Menstrual Period		Date Last PAP Smear	Abnormal PAP Smear?		Number of Sexual Partners
	Patient Had Sex With?		Partner Wear Condom?	Sex for Money?		Sex for Money Year
	Sex for Drugs?		Sex for Drugs Year	Inform Drug Partners?		Taken Street Drugs?
	Drugs Description		Last Year Took Drugs With Needle	Shared Needles?		Inform Needles Partner?
	Use Tobacco?		Duration of Tobacco Use?	Tobacco # Times Per Day		Types of Tobacco Used
	Date Quit Tobacco		Use Alcohol?	Number of Drinks Per Day		Duration of Alcohol Use
	Date Quit Alcohol
Past Medical History	Birth History		Surgeries	Hospitalizations		Family History
	Date updated		Surgeries Date	Date hospitalized		Date updated
	Birth weight		Surgery Institution Name	Hospital diagnosis		Family relationship
	Weeks gestation		Surgery type	Hospital name		Family relation age
	Birth method			Length of stay		Is relation living?
	APGAR score		Allergies			Family relation drug use
	Single or multiple birth		Allergy date			Sexual orientation
	Complications		Allergy			Family relation diagnosis
	Birth hospital		Allergy response
Physical Exam	Date updated		Site Location	Area Description		Overall Assessment
	Head Circumference		Temperature	Weight		Height
	Pulse		Respiration Rate
Chief Complaints	Date updated		Symptom	Severity		Frequency
	Duration of Illness		Resolution
Lab Tests	Date Updated		Procedure Code	Procedure Description		Results
Major Illnesses	Date Updated		History of Present Illness
Adverse Events	Date of event		Symptom	Event start date		Event end date
	Is event currently active?		Was event treated?	Physician name		Was physician intervention required?
	Was hospitalization required?		Severity	Comments
Viral Load	Date Updated		RNA Log	RNA Quantitative
T-Cell Counts	Date Updated		Total White Cell Count /cmm	Absolute Lymphocyte %		Absolute Lymphocyte /cmm
	T-Inducer Helper %		T-Inducer Helper /cmm	T-Suppressor Cytotoxic %		T-Suppressor Cytotoxic /cmm
	CD4 / CD8 Ratio
Other Doctors	Date Updated		Physician Name	Reason for Visit		Diagnosis
Oral Infections	Date Updated		Dental Clinic	Dentist’s Name		Symptom
	Diagnosis
Immunizations	Date Updated		Immunization	Immunization Site		Immunization Lot
	Manufacturer		Expiration Date
Radiology	Date Updated		Radiology Task	Anatomy Site		Radiologist’s Impressions
Medications	Date Updated		Drug Therapy	Date Started		Date Ended
	Dosage		Schedule	Route		Comments
Patient Referrals	Date Updated		Referring Physician Name	Reason
Physician Impressions	Date Updated		Diagnosis	Who Discussed With?		Is Patient Aware
	Impressions
Treatment Plan	Date Updated		Medical Problem	Treatment		Outcome
Nutritional Plan	Date Updated		Intervention Description	Number of Calories		Treatment Outcome
Chart (SOAP) Notes	Date Updated		SOAP Notes
Assessment
Pediatric Assessment	Date Updated		Informant	Informant Time		Interpreter
	FLACC Behavior		Cries?	Allergies		Apical
	Length		Weight	Respiration		Temperature
	Pulse		Head Circumference	History of Illness		Reason for Visit
	Child Developing		Child Developing Comments	Lifts Head		Regards Face
	Grasps Rattle		Social Smile	Coos		Responds to Loud Sounds
	Physical – General		Physical – Skin	Physical – Jaundice		Physical – HeadeadHead
	Physical – Fontenels		Physical – Eyes	Physical – Red Reflux		Physical – Discharge
	Physical – ENT		Physical – Lungs	Physical – Heart		Physical – Femoral Arteries
	Physical – Abdomen		Physical – Umbilicus	Physical – Hernia		Physical – Genitalia
	Physical – Testes		Physical – Hydrocele	Physical – Extremities		Physical – Hips
	Physical – Neuro		Diet – Breast	Diet – Formula		Diet – Colic
	Diet – Vitamins		Diet – Stools	Diet – Fluoride		Guidance – Lay On Bed
	Guidance – Sleep		Guidance – Interactions	Guidance – Baby sitters		Guidance – Tobacco
	Guidance – Newborn		Guidance – HB Vaccine	Guidance – DTap Number		Guidance – Hib Number
	Guidance – IPV Number		Follow-Up Plan
Child Assessment	Date Updated		Informant	Informant Time		Medications
	Allergies		Pain Feeling?	Pain Recently?		Pain Scale
	Temperature		Pulse	Respiration		Length
	Head Circumference		Weight	Risk – TB		Risk – Lead
	Risk – Cholesterol		Risk – Tobacco	Risk – Drugs		Risk – Violence
	Social – Housing		Social – Food	Social – Social Services		Social – Referral
	Health Immunizations Complete?			Health Dental Care Complete?
	Interval – Personal		Interval – Family	Physical - Skin		Physical – Head
	Physical – Eyes