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Child Follow Up
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Child Follow Up
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<htmlform>
<!-- Autogenerated example form (template from 01-Nov-2010 -->
<macros>
paperFormId = (Fill this in)
headerColor =#2f1c55
fontOnHeaderColor = white
</macros>
<style>
.section {
border: 1px solid $headerColor;
padding: 2px;
text-align: left;
margin-bottom: 1em;
}
.sectionHeader {
background-color: #2f1c55;
color: white;
/* display: block; */
padding: 2px;
font-weight: bold;
}
table tr:nth-child(even) {
background: #ffffff;
}
.alnright_s{
text-align: right;
color:#000000;
width: 13%;
}
.alnleft_s{
text-align: left;
color:#000000;
width: 13%;
}
.alnright{
text-align: right;
color:#000000;
width: 25%;
}
.alnright_i{
text-align: right;
color:#000000;
width: 40%;
}
.alnleft{
text-align: left;
color:#000000;
width: 25%;
}
td {
border: none;
}
table th, table td {
padding: 5px 10px;
border: None;
}
.legend_style {
max-width: 35%;
background: #FAFAFA;
<!--padding: 5px;-->
margin: 0px left;
box-shadow: 1px 1px 25px rgba(0,0,0,0.10);
border-radius: 2px;
border: 1px solid #305a72;
border-bottom-left-radius: 2px;
text-transform:initial;
}
form fieldset, .form fieldset {
min-width: 98%;
border: none;
border-top: 1px solid #305a72;
}
table th, table td {
padding: 5px 10px;
/* border: 1px solid #DDD; */
}
table tr {
border: None;
}
ul.select, .form input, .form select, .form textarea, .form ul.select {
padding: 2px 10px;
}
form input, form select, form textarea, form ul.select, .form input, .form select, .form textarea, .form ul.select {
padding: 2px 10px;
<!--min-width: 150px;-->
}
form select, .form select {
max-width: 200px;
min-width: 150px;
}
body {
font-family: "OpenSans", Arial, sans-serif;
color: #363463;
font-size: 14px;
}
<!--table.baseline-aligned td {-->
<!--vertical-align: baseline;-->
<!--}-->
</style>
<div class="hidden" id="encounter-details" sectionTag="section" headerStyle="title" headerLabel="Encounter Details">
<fieldset>
<legend class="legend_style">When?</legend>
<label>When?</label>
<encounterDate default="now" showTime="false" allowFutureDates="false"/>
</fieldset>
<fieldset>
<legend>Who?</legend>
<label>Who?</label>
<encounterProviderAndRole default="currentUser" encounterRole="240b26f9-dd88-4172-823d-4a8bfeb7841f" required="true"/>
</fieldset>
<fieldset>
<legend>Where?</legend>
<label>Where?</label>
<encounterLocation default="SessionAttribute:emrContext.sessionLocationId"/>
</fieldset>
</div>
<table style="margin-bottom: 20px;">
<thead>
<tr><th style="text-align: center">Child Follow Up</th></tr>
</thead>
</table>
<fieldset>
<legend class="legend_style">Mother's Information</legend>
<table width="100%">
<tr>
<td class="alnright_s">Mother Hosp. Reg. No:</td>
<td><lookup class="value" complexExpression="#foreach( $patId in $patientIdentifiers.get('Hospital Number') ) $patId #end "/></td>
<td class="alnright_s">Mother's Name:</td>
<td class="value">
<lookup complexExpression="#foreach ( $relationship in $relationshipList )
#if( $relationship.relationshipType.bIsToA == 'Child' )
#if( !($relationship.personA.patientId == $patient.patientId ))
#if( $relationship.personA.gender == 'F' )
$relationship.personA.personName
#end
#end
#end
#end "/>
</td>
<td class="alnright_s">Timing of Mother's ART Initiation:</td>
<td><obs conceptId="165940"/></td>
</tr>
<tr>
<td class="alnright_s">Hepatitis B Status:</td>
<td class="value"><lookup complexExpression="$fn.latestObs(159430).valueCoded.name"/></td>
<td class="alnright_s">Hepatitis c Status:</td>
<td class="value"><lookup complexExpression="$fn.latestObs(161471).valueCoded.name"/></td>
<td class="alnright_s"> </td>
<td> </td>
</tr>
</table>
<!--<table width="100%">-->
<!--<tr>-->
<!--<td class="alnright">Mother's Address:</td>-->
<!--<td class="value"><lookup complexExpression="#foreach ( $relationship in $relationshipList )-->
<!--#if( $relationship.relationshipType.bIsToA == 'Child' )-->
<!--#if( !($relationship.personA.patientId == $patient.patientId ))-->
<!--#if( $relationship.personA.gender == 'F' )-->
<!--$relationship.personA.personAddress.address1-->
<!--#end-->
<!--#end-->
<!--#end-->
<!--#end "/></td>-->
<!--<td class="alnright">Timing of Mother's ART Initiation:</td>-->
<!--<td><obs conceptId="165940"/></td>-->
<!--</tr>-->
<!--</table>-->
</fieldset><br/>
<fieldset>
<legend class="legend_style">Child Birth Details</legend>
<table width="100%">
<tr>
<td class="alnright">Weight at birth(kg) :</td>
<td class="value"><lookup complexExpression="$fn.earliestObs(5916).valueNumeric"/></td>
<td class="alnright">Length at birth(cm):</td>
<td class="value"><lookup complexExpression="$fn.earliestObs(1503).valueNumeric"/></td>
<td class="alnright">Head circumference at birth(cm):</td>
<td class="value"><lookup complexExpression="$fn.earliestObs(5314).valueNumeric"/></td>
</tr>
<tr>
<td class="alnright">Mid upper arm circumference at birth(cm)</td>
<td class="value"><lookup complexExpression="$fn.earliestObs(1343).valueNumeric"/></td>
<td class="alnright">APGAR Score:</td>
<td class="value"><lookup complexExpression="$fn.earliestObs(1504).valueNumeric"/></td>
<td class="alnright">Child given Hepatitis B Immunoglobulin(Hep B Ig)? at birth:</td>
<td class="value"><lookup complexExpression="$fn.earliestObs(165667).valueCoded.name"/></td>
</tr>
</table>
</fieldset><br/>
<fieldset>
<legend class="legend_style">Child Follow up Information</legend>
<table width="100%">
<tr>
<td class="alnright_s">Visit Date:</td>
<td class="alnleft_s">
<encounterDate default="now" showTime="false" allowFutureDates="false"/>
</td>
<td class="alnright_s">Weight(kg):</td>
<td class="alnleft_s"><obs conceptId="5916"/></td>
<td class="alnright_s">Length(cm):</td>
<td class="alnleft_s"><obs conceptId="1503"/></td>
</tr>
<tr>
<td class="alnright_s">Head circumference(cm):</td>
<td class="alnleft_s"><obs conceptId="5314"/></td>
<td class="alnright_s">Mid upper arm circumference(cm):</td>
<td class="alnleft_s"><obs conceptId="1343"/></td>
<td class="alnright_s">MUAC</td>
<td class="alnleft_s"><obs conceptId="165935" answerConceptIds="165932, 165933,165934" answerLabels="Over, Under, Normal"/></td>
</tr>
<tr>
<td class="alnright_s">BMI/MUAC</td>
<td class="alnleft_s"><obs conceptId="165243" /></td>
<td class="alnright_s">CTX given to child</td>
<td class="alnleft_s"><obs conceptId="165837" style="yes_no_dropdown" answerLabel=""/></td>
<td class="alnright_s">Feeding method</td>
<td class="alnleft_s"><obs conceptId="1151" answerConceptIds="5254,6046,5526" answerLabels="Infant formula,Mixed feeding,Exclusively Breastfed"/></td>
</tr>
</table>
</fieldset><br/>
<fieldset>
<legend class="legend_style">Immunization</legend>
<table width="100%">
<tr>
<td class="alnright_i">Immunization provided during 6 weeks visit:</td>
<td>
<table>
<tr>
<td width="25%">OPV 1<obs conceptId="165669" answerConceptId="783" answerLabel=""/></td>
<td width="25%">Penta 1<obs conceptId="165669" answerConceptId="1685" answerLabel=""/></td>
<td width="25%">PCV 1<obs conceptId="165669" answerConceptId="77441" answerLabel=""/></td>
<td width="25%">Rota 1<obs conceptId="165669" answerConceptId="83533" answerLabel=""/></td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="alnright_i">Immunization provided during 10 weeks visit:</td>
<td>
<table>
<tr>
<td width="25%">OPV 2<obs conceptId="165670" answerConceptId="783" answerLabel=""/></td>
<td width="25%">Penta 2<obs conceptId="165670" answerConceptId="1685" answerLabel=""/></td>
<td width="25%">PCV 2<obs conceptId="165670" answerConceptId="77441" answerLabel=""/></td>
<td width="25%">Rota 2<obs conceptId="165670" answerConceptId="83533" answerLabel=""/></td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="alnright_i">Immunization provided during 14 weeks visit:</td>
<td>
<table>
<tr>
<td width="25%">OPV 3<obs conceptId="165671" answerConceptId="783" answerLabel=""/></td>
<td width="25%">Penta 3<obs conceptId="165671" answerConceptId="1685" answerLabel=""/></td>
<td width="25%">PCV 3<obs conceptId="165671" answerConceptId="77441" answerLabel=""/></td>
<td width="25%">IPV<obs conceptId="165671" answerConceptId="82241" answerLabel=""/></td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="alnright_i">Immunization provided during 6 months visit:</td>
<td>
<table>
<tr>
<td width="50%">Vitamin A 1st Dose<obs conceptId="165672" answerConceptId="86339" answerLabel=""/></td>
<td width="20%"> </td>
<td width="20%"> </td>
<td width="10%"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="alnright_i">Immunization provided during 9 months visit:</td>
<td>
<table>
<tr>
<td width="35%">Measle 1<obs conceptId="165673" answerConceptId="79409" answerLabel=""/></td>
<td width="35%">Yellow Fever<obs conceptId="165673" answerConceptId="86556" answerLabel=""/></td>
<td width="30%">Conjugate A CSM<obs conceptId="165673" answerConceptId="79549" answerLabel=""/></td>
<td width="0%"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="alnright_i">Immunization provided during 12 months visit:</td>
<td>
<table>
<tr>
<td width="35%">Vitamin A 2nd Dose<obs conceptId="165674" answerConceptId="86339" answerLabel=""/></td>
<td width="35%">Measle 2<obs conceptId="165674" answerConceptId="79409" answerLabel=""/></td>
<td width="20%"> </td>
<td width="10%"> </td>
</tr>
</table>
</td>
</tr>
</table>
</fieldset><br/>
<fieldset>
<legend class="legend_style">EID Lab Monitoring</legend>
<table class="table" width="100%">
<tr>
<td class="alnleft_s"><b>PCR Lab Monitoring</b></td>
<td class="alnleft_s"><obs id="pcr" conceptId="165868" answerConceptIds="165865,165866,165867 " answerLabels="1st PCR, 2nd PCR, Confirmatory PCR">
<control>
<when value="165865" thenDisplay="#pcr_1"/>
<when value="165866" thenDisplay="#pcr_2"/>
<when value="165867" thenDisplay="#confirmatory_pcr"/>
</control>
</obs></td>
<td colspan="4"> </td>
</tr>
</table>
<table id="pcr_1" class="table" width="100%">
<tr>
<th>Date Sample Collected</th>
<th>Date Sample Sent</th>
<th>Date Result Received at Facility</th>
<th>Date Caregiver Given Result</th>
<th>PCR Result</th>
</tr>
<tr>
<obsgroup groupingConceptId="165875">
<td><obs conceptId="165869"/></td>
<td><obs conceptId="165870"/></td>
<td><obs conceptId="165874"/></td>
<td><obs conceptId="165873"/></td>
<td><obs conceptId="165872" answerConceptIds="703,664,165871" answerLabels="Positive, Negative, Not Processed"/></td>
</obsgroup>
</tr>
</table>
<table id="pcr_2" class="table" width="100%">
<tr>
<th class="alnleft">Date Sample Collected</th>
<th class="alnleft">PCR Result</th>
</tr>
<tr >
<obsgroup groupingConceptId="165875">
<td ><obs conceptId="165869"/></td>
<td ><obs conceptId="165872" answerConceptIds="703,664,165871" answerLabels="Positive, Negative, Not Processed"/></td>
</obsgroup>
</tr>
</table>
<table id="confirmatory_pcr" class="table" width="100%">
<tr>
<th class="alnleft">Date Sample Collected</th>
<th class="alnleft">PCR Result</th>
</tr>
<tr >
<obsgroup groupingConceptId="165875">
<td ><obs conceptId="165869"/></td>
<td ><obs conceptId="165872" answerConceptIds="703,664,165871" answerLabels="Positive, Negative, Not Processed"/></td>
</obsgroup>
</tr>
</table>
<table class="table" width="100%">
<tr>
<td class="alnleft_s"><b>Rapid Test Antibody Lab Monitoring</b></td>
<td class="alnleft_s"><obs conceptId="165879" /></td>
<obsgroup groupingConceptId="165880">
<td class="alnright_s">Rapid Test Date</td>
<td><obs conceptId="165025"/></td>
<td class="alnright_s">Rapid Test Result</td>
<td><obs conceptId="165026" answerConceptIds="703,664,1138" answerLabels="Positive, Negative, Indeterminate"/></td>
</obsgroup>
</tr>
</table>
</fieldset>
<fieldset>
<legend class="legend_style">Comments and Signature</legend>
<table width="100%">
<tr>
<td class="alnleft">Comment:</td>
<td colspan="3"><obs rows="2" conceptId="161011"/></td>
</tr>
<tr>
<td class="alnleft">Clinician</td>
<td class="alnleft"><encounterProvider /></td>
<td class="alnleft">Facility:</td>
<td class="alnleft"><encounterLocation default="SessionAttribute:emrContext.sessionLocationId"/></td>
</tr>
</table>
</fieldset><br/>
<submit/>
</htmlform>