New Distress Management Survey


Personal Information:












African American / Black
American Indian or Alaska Native
Asian
Hispanic or Latino
Other Race
White / Caucasian



:
Yes No
Last treatment date:




Yes   No  
Formal  Informal 

Distress Level

10
9 Stressed
8
7
6
5 Sad
4
3
2
1 Happy
0
Not Reported

Causes

Cognitive Problems
Yes   No  
Feeling confused
Yes   No  
Forgetfulness
Yes   No  
Poor thinking
Yes   No  
Seeing/hearing things
Emotional Problems
Yes   No  
Adjusting to changes in appearance
Yes   No  
Adjusting to my illness
Yes   No  
Dealing with children
Yes   No  
Depression
Yes   No  
Fears
Yes   No  
Indigestion
Yes   No  
Isolation/Feeling alone
Yes   No  
Loss of interest in usual activies
Yes   No  
Nervousness/Anxiety
Yes   No  
Nose dry/congested
Yes   No  
Sadness
Yes   No  
Worry
Family Problems Dealing With
Yes   No  
Ability to have children
Yes   No  
Dealing with Partner
Yes   No  
Family Health Issues
Yes   No  
Partner
Information Concerns
Yes   No  
Lack of information about maintaining fitness
Yes   No  
Lack of information about my alternative therapy choices
Yes   No  
Lack of information about my diagnosis
Yes   No  
Lack of information about my treatment
Other
Yes   No  
Language barrier
Physical Problems
Yes   No  
Appearance
Yes   No  
Bathing/dressing
Yes   No  
Breathing
Yes   No  
Constipation/diarrhea
Yes   No  
Fatigue
Yes   No  
Fevers
Yes   No  
Getting around
Yes   No  
Loss of appetite
Yes   No  
Memory/Concentration
Yes   No  
Mouth sores/swallowing
Yes   No  
Nausea/Vomiting
Yes   No  
Pain
Yes   No  
Sexual problems
Yes   No  
Skin dry/itchy
Yes   No  
Sleep/Insomnia
Yes   No  
Substance abuse
Yes   No  
Swollen arms/legs
Yes   No  
Talking
Yes   No  
Tingling hands/feet
Practical Problems
Yes   No  
Child Care
Yes   No  
Eating
Yes   No  
Financial issues
Yes   No  
Housing
Yes   No  
Insurance
Yes   No  
Transportation
Yes   No  
Treatment Decisions
Yes   No  
Work/school
Spiritual/Religious Concerns
Yes   No  
Facing my mortality
Yes   No  
Loss of faith
Yes   No  
Loss of my sense of purpose
Yes   No  
Relating to God
Yes   No  
Spirtiual/Reglious Concerns

Notes

Treatment Options
Do you desire to be contacted regarding any of the distress listed? Yes   No


Version Updates

2.11.12

• Fix issue with removing diagnoses • Fix for HL7 response and version information

2.11.13

• Update the HL7 process to check the project configuration on whether it should insert patients that do not exist. • Store MSH-10 with each test result into the diagnostic procedures. • Update Hl7 - OBR/OBX to show Observation title only once

2.11.14

• Create Journey Forward Role mappings • Fix issue where the Reset functionality on the ad hoc does not reset all the fields. • Fix issue where the clinical-trial Y/N filter is not remembered when saving an ad hoc report. • Update diagnostic procedures to store treatment facility. • Update adhoc report to be filterable by treatment facility. • Add Diagnosis Groups feature. • Fix issue with hl7 server sometimes not recognizing the end of a message • Add PDF attachments for patient diagnostic procedures • Make it possible to select multiple Resources for barrier interventions. • Add a new "Save and Continue" button for Barrier Resolution which will submit the form data and then reload the same page, instead of going back to the main Barriers page. • Updated Reports to display popup, and disable submit button while the report is running

2.11.15

• Fix providers' portal so that it can load diagnosis groups. • Add display for the filename of an attachment if one exists while editing documentation items • On patient-view, move status next to pencils in header • Update the Barrier Intervention tab to show the barrier in question • Fix drop-downs on Specialties/Diagnoses to be populated by id instead of title, and sort the list of specialties by name • Update the Journey Forward exporter to look for a matching diagnosis group if it doesn't find a match on the diagnosis

2.11.16

• Fix 500 error when updating a diagnosis group • Add diagnosis group column to Diagnoses admin page • Update Ad-Hoc Report form submission to only show pop-up when 'Submit' is pressed • Update Followup Cares admin page to have a multi-tab display

2.12

• Make sure the diagnosis group drop-downs in followup cares and surveillances only show active groups • Add messaging system • Trigger event alerts for navigator(s) when patient fills out new distress survey • Add a "select all" feature to all of the pop-ups on the ad-hoc reports page • Add medications and medical history to the patient portal

2.12.1

• Move "My Account" link next to Logout and make Event Alerts page and pop-ups be based on the navigator selected in the upper right corner • Fix Referral To and Referral From fields in ad-hoc reports

2.12.2

• Add attachment support to insurances • Fix HL7 server to be able to handle empty lines in messages • Preserve line breaks in PDF generated from HL7 messages • Send providers to the same place as navigators, with read-only access • Add ability for super-admins to export entire database to CSV's • 832 add Super-Admin setting to enable/disable messaging system