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Table 1 The SISAM-13 information fields

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
  E-mail  
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  
  E-mail  
  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  
  1. ICD-10 the International Statistical Classification of diseases and related health problems, Version 10