NHCSC

All Fields are Mandatory i.e. Don't Leave Blanks; Fill N/A where Response is not applicable!
To Add a Clinical Visit, click the button labelled "Add Clinical Visit" then fill in the details and submit - Repeat the same to add another visit. In-Case you encounter any problem while filling the Clinical Summary Form Online: Call the Number 0726 460 000 for Assistance.

To be able to save your work as a draft, you must at least fill in all values from the beginning to the variable requesting for the facility email.

MINISTRY OF HEALTH

NATIONAL AIDS AND STI CONTROL PROGRAMME

CLINICAL SUMMARY FORM

Facility:

Patient’s CCC No: (Do not write name)

Case Reporting Date:

Patient Details

Date of Birth:

ART Start Date:

Gender:

Current Weight (Kg):

Height (cm):

Clinician’s Name:

You can add three (3) email addresses by separating them with either the space bar, comma, semi-colon, tab key or return/enter key.

Facility Email Address:

Facility Tel No:

What is the primary reason for this consultation:

Adverse drug reaction

Private cross-over patient

Single TDF out of stock

Drug interactions

Second line failure

Study cross-over patient

First line failure

Single AZT out of stock

Other (Please Specify)

Other Primary Reason

Clinical Evaluation: history, physical, diagnostics, working diagnosis:(excluding the information in the table below)

Clinical Evaluation: history, physical, diagnostics, working diagnosis (excluding the information in the table below Complete the table below chronologically, including all ART regimens and laboratory results (and any previous history available for transfer-in patients)

#	Date (yyyy-mm-dd)	CD4	HB	CrCl/ eGFR	Viral Load	Weight	ARV Regimen	Reason for Switch	New OI	Actions
{{ clinical_visit_index+1 }}	{{ clinical_visit.clinicvisitdate }}	{{ clinical_visit.cd4 }}	{{ clinical_visit.hb }}	{{ clinical_visit.crclegfr }}	{{ clinical_visit.viral_load }}	{{ clinical_visit.weight_bmi }}	{{ clinical_visit.arv_regimen }}	{{ clinical_visit.reason_switch }}	{{ clinical_visit.new_oi }}

Adherence and Treatment Failure Evaluation

Number and findings of adherence counselling/assessment sessions done in the last 3-6 months including the following:

    Findings from MMAS-8
    Adherence barriers identified
    Recommendations

Number of home visits conducted in last 3-6 months, and findings:

Describe support structures (e.g. treatment buddy, support group attendance, caregivers) in place for this patient

Evidence of adherence concerns (e.g. missed appointments, pill counts?):

Describe daily witnessed ingestion done in last 3-6 months (Who performed it, which tool was used, how long was the session done etc.):

Describe likely root cause/s of poor adherence, for this patient (e.g. stigma, disclosure, side effects, alcohol or other drugs, mental health issues, caregiver changes, religious beliefs, inadequate preparation, etc):

Evaluation for other causes of treatment failure, e.g.

• Inadequate dosing/dose adjustments (particularly for children)::

• Drug-drug interactions:

• Drug-food interactions:

• Impaired absorption (e.g. chronic severe diarrhea):

Other Relevant ART History.

Comment on treatment interruptions, if any:

Has Drug Resistance/Sensitivity Testing been done for this patient? If yes, state date done and attach the detailed results.

Has facility multidisciplinary team discussed the patient’s case?. If yes, comment on date, deliberations and recommendations.
(indicate how treatment failure was established and confirmed, proposed regimen and dosage, current source of drugs if patient already on 3rd line). If yes, state date done and attach the detailed results:

MDT members who participated in the case discussion (names and titles)

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National HIV Clinical Support Center

MINISTRY OF HEALTH

NATIONAL AIDS AND STI CONTROL PROGRAMME