Table 1 The SISAM-13 information fields

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