Background
Case presentation
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 |
“I can forward (for hospitalization) […] I put [a patient] in the system, which is the SISAM, a patient with psychotic outbreak, suicide attempt, self-harm. There’s a place I can do that and see where he has gone”. (General Practitioner)
“The SISAM is working well. We are using it more to see or to request hospitalizations and all patients who are now going through consultations I register with the SISAM”. (Community mental health service manager 1)
“The SISAM that also makes it easier for us, we can see if there is a patient from the outpatient clinic that is waiting for a vacancy and talk about that patient or family member looked after by us, finally we can make this exchange [of information]. ”(Community mental health service manager 2)
“A patient escaped from a [psychiatric] hospital and he came here […] I knew that I had requested his hospitalization by the SISAM in this psychiatric hospital, […] she should have come with a [discharge] conuter-reference. He came without it. This is how we found out [that he escaped]” (Community mental health service manager 3)