From: A web-based information system for a regional public mental healthcare service network in Brazil
Information type | Details |
---|---|
Patient sociodemographic information | |
Patient information | |
Patient’s name | |
Mother’s name | |
Date of birth | |
National identification | Identity card number |
Taxpayer registry identification | Individual taxpayer registry identification number |
Public healthcare identification | National health card number |
Gender | Male, female, transsexual |
Address | Street, district, state, city, zip code |
Telephone | Residential, mobile phone, work |
Race/ethnicity/skin colour | Black, white, yellow, indigenous, brown |
Marital status | Married, single, divorced, widow/widower |
Living arrangements | Living with a partner, parents, children, other family members, acquaintances/friends, alone, other |
Occupation | |
Spouse, emergency contact, next of kin or carer’s information | |
Name | |
Relationship | Spouse, brother/sister, father/mother, other |
Service administrative information | |
User’s information | |
Name | |
Gender | Male, female, transsexual |
Type of professional council | Regional Council of Medicine, nursing, psychology, social service, physiotherapy, nutritionist, lawyers, other |
Professional registration number | |
Issuing authority | |
Telephone | Residential, mobile phone, work |
System registration date | |
Login | Username, password |
Current place(s) of work | |
Type of the system access permission | Psychiatrist, physician, resident physician, others health professional, shared use within the service, service manager, service secretary, system administrator, judge |
Service’s information | |
Service | Name, Address, State, Zip Code, City |
Type of health service | Primary health care, mental health outpatient, mental health hospital, emergency outpatient, emergency hospital service |
Regional Health Department | Name |
Contact | Email, telephone |
Number of beds | |
Type of bed | Male, female, both |
Hospital ward | |
Patient’s medical history information | |
Outpatient care | |
Service | Name |
Referral date | |
Type of referral | Scheduled new case, scheduled return, counter-reference, emergency/clinical intercurrence, workshop |
Professional(s) involved in the patient´s care | Physician, social worker, nurse, nursing technician, dentist, physiotherapist, psychologist, physical educator, speech therapist, pharmacist, occupational therapist, nutritionist, other |
Type(s) of care | Individual, group, family care, home visit, workshops, psychosocial rehabilitation, other |
Reference and counter-reference | |
Type | Reference/counter-reference |
Date | |
Responsible healthcare professional | |
Service/municipality of origin | |
Destination service/municipality | |
Motive | |
Requests for hospitalization | |
Requesting health professional | |
Service/municipality of origin | |
Hospital/municipality service | |
Overnight stay at the service of origin | Yes/no |
Message history between health professionals | |
Request for hospitalization history | |
Name of the judge | Judiciary request for information |
District Attorney | Judiciary request for information |
Applicant | Judiciary request for information |
Judicial district | Judiciary request for information |
Case number | Judiciary request for information |
Number of the judicial process | Judiciary request for information |
Judicial order number | Judiciary request for information |
Compulsory indication | Treatment for chemical dependency, treatment for mental disorder, other |
Judicial injunction | Judiciary request for information |
Hospitalization | |
Hospital/municipality | |
Medical record number | |
Bed number | |
Responsible healthcare professional | |
Hospitalization date | |
Type of hospitalization | Determined by a judicial authority, determined by a psychiatrist without patient’s consent, determined by a psychiatrist with patient’s consent |
Service of origin | Name, Municipality |
Requesting health professional | |
Date of discharge | |
Type of discharge | By a psychiatrist, at the request of the patient or his/her family, administrative (ex. due to patient’s misbehaviour), escape, death, inter-hospital transfer in the network or transfer to other medical specialities |
Name of the professional responsible for discharge | |
Inter-hospital transfer destiny | |
Motive for inter-hospital transfer | |
Patient clinical information | |
Outpatient care | |
Primary diagnosis | According to the ICD-10 |
Other diagnosis | According to the ICD-10 |
Summary | Summary of the patient’s consultation/activity/workshop |
Request for hospitalization | |
Motive for request | Abstinence from use of psychoactive substances, psychomotor agitation, self-harm/hetero-aggressive behaviour, delirium tremens, suicidal ideation, psychoactive substance intoxication, judicial request, first psychiatric outbreak, severe depressive illness, maniac outbreak, other |
Hypertension | Yes, no, no information |
Diabetes | Yes, no, no information |
Infectious disease | Yes, no, no information |
Trauma | Yes, no, no information |
Respiratory problems | Yes, no, no information |
Sequelae of cerebrovascular accident | Yes, no, no information |
Epilepsy | Yes, no, no information |
Others comorbidities | Name |
Medical exams | |
Medication | |
Initial diagnostic hypothesis | According to the ICD-10 |
Other diagnostic hypothesis | According to the ICD-10 |
Treatment modality | Intensive, non-intensive, semi-intensive |
Hospitalization | |
Motive for hospitalization | Abstinence from use of psychoactive substances, psychomotor agitation, self-harm/hetero-aggressive behaviour, delirium tremens, suicidal ideation, psychoactive substance intoxication, judicial request, first psychiatric outbreak, severe depressive illness, maniac outbreak, other |
Primary diagnosis | According to the ICD-10 |
Other diagnosis | According to the ICD-10 |
Discharge primary diagnosis | According to the ICD-10 |
Discharge other diagnosis | According to the ICD-10 |
Comorbidities | |
Initial medication | |
Discharge medication | |
Medical exam results | |
Summary of clinical history | |
Treatment |