Oncology
HEMOPHILIA
Return Encounter Form v1.0
First Name:
person_name.given_name
Middle Name:
person_name.middle_name
AMRS ID:
patient_identifier_type_id=8
Date:
encounter_encounter.datetime:
Last Name:
person_name.family_name
Hospital ID (OP/IP):
Hospital Name:
patient_identifier_type_id=15 (inpatient) encounter_id
patient_identifier_type_id=12
(outpatient)
Date of Birth:
Person.birthdate
If Birth-date Unknown, Age:
Sex: □M □F
Person.gender
Tribe:
person_attrbute_type_id=20
County:
person_address.state_province
NHIF 6266
6815 (yes), 1107 (no)
Clinic Site: encounter.location_id □MTRH □ Chulaimbo □ Busia □ Webuye □ Kitale
□ Other (specify):
Phone Number #1
Phone #2
Patient
person_attribute_type_id=10
person_attribute_type_id=40
Next of Kin (Caretaker)
person_attribute_type_id=25
person_attribute_type_id=61
PAST MEDICAL HISTORY
Are you currently being treated for any of the following
illnesses?6245
Are you allergic to any
medications?(7111)
□ HIV (884)□ Hepatitis (29)□ High Blood Pressure(903)
□ Yes (1065)
□ Diabetes (175)□ Other(5622)
□ No (1066)
if yes check all that apply
□Penicillin(6011)
□Sulfa(6012)
□ Other (specify) (1083) 2089
Please list the exact medication(s) you are currently taking:(8786)
Drug Name: (8786, 1895)
Route: (8786, 7463)
Dosage(mg): (8786,2206)
Reason for use:(8786,1190)
Start Date: (8786,1190)
Duration(weeks):(8786,1893)
Drug
Name1895
Reason for
Use 9222
1915
Date
Started
1190
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)
Please list the surgeries:(6478)
□Orthopedic Surgery(8750) □Laporatomy (7157) □Cauterization for Epistaxis(8752) □Uvulectomy(8753)
□Athrotomy(8754) □Head surgery(8755) □Circumcision(2062) □Tooth Extraction(1980) □Other(5622)
Date of Discharge from most recent
No. of febrile illnesses since last clinic
(8744)Type of Transfusion: (8744, 8743)
hospitalization: (7688)
visit (8411)
#Whole Blood (1000)
Oncology Hemophilia Return Encounter Form v1.0
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#Packed red blood cells (preferred) (8745)
#FFP (8746)
#Cryoprecipitate(8747)
#Plasma Derived Clotting Factor Concentrate
(8748)
#Recombinate Clotting Factor (8751)
#Factor VIII(8774)
#Factor IX (8775)
Number of Units Transfused: (8744, 8412)
Date of Transfusion: (obs.datetime of 8743)
Details of Major Bleeding Events 8756
Type of bleed (8756, 1239)
# of Bleeds
Hospitalizatio Type of Transfusion Received 8756, 8743 Resolution
□Head Bleeds (8757)
(8756, 8776) n (8756, 6419)
□
□Abdominal Bleeds (1350)
□Joint Bleeds (8758)
□Nose Bleeds (8761)
□Oral Bleeding (7941)
□Soft tissue bleeds (8759)
#Whole Blood (1000)
Status
#Packed red blood cells (preferred)(8745) (8756, 8762)
Duration Per:
(8756, 8777)
□Weeks(1073)
#FFP (8746)
# Completely
#Cryoprecipitate (8747)
#Plasma Derived Clotting Factor
Concentrate (8748)
#Recombinate Clotting
Factor (8751)
#Factor VIII (8774)
#Factor IX (8775)
(1267)
□Months(1074)
#Partially
□Years(8787)
(7084)
#Unresolved
(8788)
□Muscle bleeds (8760)
□Other bleeds (5622)
Excessive bleeding with circumcision
□Yes(8763 , 2062)
□No(8764, 2062)
□N/A(8765, 2062)
Excessive Bleeding with Immunization
□Yes(8763 , 6784)
□No(8764, 6784)
□N/A(8765, 6784)
Prolonged bleeding with dental procedures
□Yes(8763 , 1902)
□No(8764,1902)
□N/A(8765, 1902)
How many months, during the past year, did the patient use Crutches or a Cane? ____ (8766)
REVIEW OF SYSTEMS
From where were you referred to our clinic?(6749)
Why are you coming to our clinic?(1834)
□ MTRH Staff(1274)
□ Scheduled Clinic(1246)
□ Non-MTRH Staff(6479)
□Symptoms(1068)
□ Self-Referral(978)
Chief Complaint:5219□ Feeling well(5006) □ Bleeding(2376) □Swelling(6001) □Joint Pain(80) □ Having symptoms(1068)
Notes:
General: (1069)□ No Complaints(664) □ Fever/Chills (5945/871)□ Pain(6613) □ Fatigue(5949) □ Jaundice(5986) □ None(1107)
HEENT: (1070)□ No Complaints(664) □ Hearing Difficulties(861) □ Swallowing Difficulties(5954) □ Vision Difficulties(5953)
Notes:
Cardiopulmonary: (1071)
□NoComplaints (664)
Chest Pain (136)
□ Days(5971, 1072) □ Weeks (5971,
1073) □ Months(5971, 1074)
Oncology Hemophilia Return Encounter Form v1.0
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□Cough (107)□ days (5959, 1072) □ weeks(5959, 1073) □ months(5959, 1074) Location (5976) □Sub Sternal(5973) □Right(5141)
Cough Quality (5958) □white(1075) □purulent(1076) □bloody(1077)
□SOB (5960) 5962□ days(1072) □ weeks(1073) □ months(1074) - □ at
□Left (5139) □Posterior(541)
Notes:
rest(5961) □ on exertion(5963)
Gastrointestinal: (1078) □ No Complaints (664)
□ Abdominal pain 151 (2007) □ days(2007, 1072) □
□Dysphagia(881) □ days (6719, 1072) □ weeks(6719, 1073) □ months(1074)
weeks(2007, 1073) □ months(2007, 1074)
□ Jaundice (215)
Location (1884)□ RUQ(5107) □ RLQ(1882) □
□ days(6720, 1072) □ weeks(6720, 1073) □ months(6720,
1074)
LUQ(1883) □ LLQ (5104) □ Epigastric(5099) □
□ Lack of Appetite (6031) □ days(6721,1072) □ weeks(6721, 1073) □
Suprapubic(575)
Notes:
months(6721, 1074)
□Constipation(996) □ Diarrhea(16) □ Melena(6494)
□ Bleeding per Rectum(6495)
Genitourinary: (1080) □ No Complaints (664)
□ Dysuria (6020)
LMP ___/____/________ (1836)
Frequency: □ Increased Urine Volume (8417)
□Priapism 8767
□Blood in urine 840
□ Reduced Urine Volume (6021)
Musculoskeletal: (1081)
□ Pain (6034) □ Days (8591,1072) □ Weeks (8591, 1073) □
□ No Complaints (664)
Months(8591, 1074)
□ Edema of Legs(590)
Location (6696) □Neck(6598) □ RUE(1233) □ LUE(1232) □
□ Leg Ulcers(951)
RLE(1235) □ LLE(1234) □Back (6601)
□Swelling (6001)
□Chest(1349) □
Buttocks(6597)□Knee(8768)□Wrist(8769)□Ankle (8770 □Elbow
8771 □Hip 8772 □Shoulder 8773
Central Nervous System: (1082)□ No Complaints (664)
□ Parathesia (6004) □ Focal Weakness (6005) □ Seizures(206)
Notes:
□ Headache(620)
□ Confusion(6006)
PHYSICAL EXAMINATION
Vitals: (1114) BP(6411) 5085/5086
Weight (5089)kg
Pulse(5087) beats/min
Height (5090) cm
Resp Rate (5242) Temp [oC] (5088)
BSA (980)
m2
Sat.O2…………% 5092
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:
HEENT: (1122)
□ Not Done (1118)
□ Normal (1115)
Notes:
Eyes:
□ Scleral Icterus(5192)□ Pale
Conjunctiva(516)
Neck:
□ Deviated Trachea(513)
Mouth
□ Nuchal Rigidity(5170)
□ Other lesions(6672)
□Thrush(5334)
Chest: (1123)
□ Not Done (1118) □Normal (1115) □ Dullness to percussion(5138) □ Breath Sounds Diminished(5115)
Oncology Hemophilia Return Encounter Form v1.0
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□ 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)
□ Tender to Palpation (5105)
Abdominal Tenderness Location
(1884)
□RUQ(5107)
□ RLQ (1882)
□Hepatomegaly(5008)cm below costal margin
(5153)
□Splenomegaly(5009)cm below costal margin
(5195)
□Ascites(581)
□Mass(5103)
□ LUQ (1883) □ LLQ (5104) □
Epigastric(5099)
□ Suprapubic(575)
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)
□ Edema (590) □ Leg Ulcers(951) □ Cellulitis(134)
□ Kaposi's sarcoma(507) □ Mass(582)
□ Not Done (1118)
□ Normal (1115)
Nodal Survey: (1121)
□Generalized Lymphadenopathy 8261
□Submandibular(504) □ Supraclavicular(505)
□ Not Done (1118)
□Lymphadenopathy(161)
□Cervical(643) □ Axillary (5112) □ Inguinal (506)
□Normal (1115)
(Record Location)
□ Other (5622)
□Abnormal(1116)
Musculoskeletal: (1128)
□ Not Done (1118)
Neurologic: (1129)
□ Cranial Nerve
□ Not Done (1118)
Abnormality(599)
□ Normal (1115)
□ Abnormal (1116)
□ Decreased Sensation(497)
□ Abnormal Gait(5108)
□ Normal (1115)
LAB RESULTS:
Chemistry
Serum electrolytes (5473)
Complete Blood Count
□ Serum Calcium (2324) ___mg/dLTest Date __/___/___
□ Serum Creatinine (790) ___µmol/L Test Date __/___/___
□Serum uric acid test (6134)
□Serum bicarbonate (1135)___
□Serum chloride (1134)____
□Serum potassium (1133)__
□Serum sodium (1132)_____
□ Hematocrit (1015)
____ %
□ Hemoglobin (21)____g/dL
Test Date ___
Test Date _____
□ Mean corpuscular volume (851)___fL Test Date _____
□ Platelets count (729)___10^3/µL Test Date _____
□ Serum white blood cells count (678)___10^3/µLTest Date
_____
□ Absolute neutrophil count, automated (1330)_10^3/µL
Date _____
□Retic % (1327)___
Test Date _____
Oncology Hemophilia Return Encounter Form v1.0
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Test
Hepatic Function
Urinalysis(302) Test Dates for each _____
□Serum glutamic-pyruvic transaminase (654)____
□urinalysis, microscopic (1986)___
□Serum glutamic-oxaloacetic transaminase (653)___
□presence of pus cells, urine (1984)___
□Serum alkaline phosphatase (785)____
□presence of red blood cells, urine (1985)__
□Serum direct bilirubin (1297)____
□presence of protein, urine (2339)
□Serum total bilirubin (655)____
□presence of sugar, urine (2340)
□Serum total protein (717)____
% Plasma Cells in Bone Marrow Aspirate ___% (8593)
UPEP: 8596
Albumin: 849
Alpha-1 Globulin: 8737
Alpha-2 Globulin: 8738
Beta Globulin: 8739
Gamma Globulin: 8740
M Protein: 8736
SPEP: 8595
Albumin: 848
Alpha-1 Globulin: 8732
Alpha-2 Globulin: 8733
Beta Globulin: 8734
Gamma Globulin: 8735
M Protein: 8731
IMAGING RESULTS(6500) Test Dates for each _____
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-Ray(12) Test date___/___/_____
Code : 0=normal(1115) 1=PI Effusion1(136) 2=Infiltrate(6049) 3=milliary(1137) 5=Cavitary(6052)4=Diffuse abn/non-milliary(6050) 6
= Cardiomegaly5158 7=other abnormality(5622)
X-Ray Type: (6897) ______ Result _____ Date __/___/___
X-RAY, SHOULDER (394)X-RAY, PELVIS (392)X-RAY, ABDOMEN (101)X-RAY, OTHER (309)
X-RAY, SKULL (386)X-RAY, LEG (380)X-RAY, HAND (382)X-RAY, FOOT (384)X-RAY, ARM (377)
X-RAY, SPINE (390)X-Ray, Chest (12)BARIUM SWALLOW (Esophagus X-ray) (1513)BARIUM MEAL (1512) (Upper GI, X-ray)
CT Scan: (6501) _____ Result______ Date: __/__/____
CT Head (846)CT Abdomen (7114) CT Chest (7113)
Ultra Sound: (6502) _____ Result______ Date: __/__/____
ULTRASOUND, RENAL □ Patient reported (7115) □ Radiologist reported (7115)
ULTRASOUND, HEPATIC □ Patient reported (852) □ Radiologist reported (852)
OBSTETRIC ULTRASOUND □ Patient reported (9221) □ Radiologist reported (6221) Test
ABDOMINAL ULTRASOUND □ Patient reported (845) □ Radiologist reported (845)
Other Tests (Radiology)8190
DIAGNOSIS
(8793, 6042) Bleeding Disorder Diagnosis: Hemophilia A(8789)
(8793, 8792) Severity: Severe (1745)
 Moderate (1744)
(8794) Baseline factor-8 activity level:……%
 Hemophilia B (8790) VWD (8791)Other: (5622)
 Mild (1743 ) Unknown (1067)
(8796)Laboratory confirmation by AMPATH Hematology
 Yes (1065)  No (1066)  Don’t Know (1624)
Obs.datetime for 8796 If yes, Date of lab:……/… .../……….
Oncology Hemophilia Return Encounter Form v1.0
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PLAN
Physical Therapy 8781 (1239, 8264)
Areas of Concern:
Joints8781, 1239
8781, 8264
Ankle (8770)Right (5141) Left (5139) Both (2399)
Knee (8768)
Right (5141) Left (5139) Both (2399)
Hip (8772)
Right (5141) Left (5139) Both (2399)
Wrist (8769) Right (5141) Left (5139) Both (2399)
Elbow (8771) Right (5141) Left (5139) Both (2399)
Shoulder (8773) Right (5141) Left (5139) Both (2399)
Other: 5622
Muscles (8781, 1239)(8781, 8264)
Hamstring (8782) Right (5141) Left (5139) Both(2399)
Biceps Brachii (1345)Right (5141) Left (5139) Both
(2399)
Calf(Gastrocnemius) (1347)Right (5141) Left (5139)
Both (2399)
Hip Flexor (Iliopsoas) (8783)Right (5141) Left (5139)
Both (2399)
Thigh (quadriceps)(1348)Right (5141) Left (5139)
Both (2399)
Hip Extensors(8784)Right (5141) Left (5139) Both
(2399)
 Fingers (8785)Right (5141) Left (5139) Both (2399)
Others
Activity Level (8797)
(8798) Unrestricted (Patient has few or no signs of joint disease)
(8799) Some limitation (Patient has independent mobility but
some restriction due to joint disease)
(8800) Very limited (Patient can move around independently but
with difficulty)
(8801) Assistance required (Patient needs a wheelchair or help
form others to more around
Which of the following assistance device does the patient need?
(1705)
Cane (8802 )crutches (8805)Walker(8806)Wheelchair
(8803)Neck Support (8807)Chest Support (8804)Back
Support (8808)Elbow Support (8809) Wrist Support (8810)
Hand support(8811)Thigh support (8812) Knee support
(8813) Ankle Support(8814) Foot Support (8815) Shoulder
Support(8816)
None(1107)
Education Provided: (6327)
Isometric Exercises 8817
Active Exercises7055Flexibility Exercises 8818Resistive Exercises 8819
Gait Training 8820
RICE flexibility 8821Wrapping 8822 Signs/Symptoms of Bleeding2376
Activity Modification 8823
Adaptive Equipment/Bracing 8824
Hemophilia Treatment Plan: (8726)
8726, 8743 Transfusion:
#Whole Blood 1000
#Packed red blood cells (preferred) 8745
#FFP 8746
#Cryoprecipitate 8747
#Plasma Derived Clotting Factor Concentrate 8748
#Recombinate Clotting Factor8751
#Factor VIII 8774
#Factor IX 8775
8726, 8412 Number of Units:
8726, 1190 Start date:
Please document all other medications prescribed, especially prophylactic treatment and pain medications:
(If Start drugs, then display) 8726
Drug Name: 8726, 1895
Route:8726, 7463
Dosage (mg): 8726, 1899
Start Date:8726, 1190
Reason for use: 8726, 2206
Duration (weeks):8726, 1893
(If Change drugs, then display)8726
Drug Name: 8726, 1895
Route:8726, 7463
Dosage (mg): 8726, 1899
Start Date:8726, 1190
Duration (weeks):8726, 1893
Reason for Change (8726, 8414) □ Completion 1267 □ Toxicity 1879 □ Progression/regimen failure 843
Oncology Hemophilia Return Encounter Form v1.0
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(If Stop drugs, then display)8726
Drug Name:8726, 1895
Stop Date: 8726, 1191
Reason for Stop (8726, 8414) □ Completion 1267 □ Toxicity 1879 □ Progression/regimen failure 843
Referral: 1272
□Physical Therapy (1905)
□Orthopedic team 8825 □Social Worker(1580)
□Dentistry1902
Reason for Referral (2327)
Return To Clinic After:
Return To Clinic Date:
/
/
(5096)
Form Completed By:provider_id encounterProvider
Nurse
Provider #
Clinician
Provider #
Oncology Hemophilia Return Encounter Form v1.0
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