Patient IPS Passport Generator

Notes: this is not a medical history, not intended to be complete enough to enable disability/impairment related care (or any other kind of care). It’s intended to be a general statement to all carers of general care guidelines and functional issues they need to be aware of for any/general provision of care. Also note that this is not a beautifully crafted user interface; it’s a sample interface intended to help people discuss/describe the requirements for these kind of statements.

## Patient Details
Patient
Consumer Name(mandatory)
Date of Birth(mandatory, YYYY-MM-DD)
National Health Identifier(optional)
Country Code(optional - 2 or 3 letter code)
Email(optional)
Mobile Phone(optional)
Phone(optional)
Next of Kin
Name(optional - leave all blank if not desired)
Email(optional)
Mobile Phone(optional)
Phone(optional)
Author
Name(optional - leave blank for self-authored)

Care Planning / Advance Directives

Care Advocate
Name(optional - leave all blank if no care advocate)
Email(optional)
Mobile Phone(optional)
Phone(optional)
Status Legal Power of Attorney(check if care advocate has legal rights)

Is there anyone we should avoid contacting, or speaking to, on your behalf - for example, due to an avoidance relationship / family issues?


Note: Providing Names + Relationship works best (one per line)

Check any appropriate:

  • I consent to all treatments aimed at sustaining or prolonging my life OR
    I refuse any treatments aimed at sustaining or prolonging my life (DNR) SCT 439569004
  • I am willing to be an organ donor OR
    I am NOT willing to be an organ donor SCT 1148553005
  • I consent to receive a blood transfusion OR
    I do not consent to a blood transfusion SCT 116859006

If you have a full Advance Care Directive, attach it here (as a .pdf):

Gender / Cultural Identity

Culture(optional - leave blank if not important)
Gender or (optional)
I have variations from
typical sex characteristics 		(optional)
Pronouns or (optional)
Your placeFill out your country and/or your community if important
Preferred Language I can get by in English (e.g. or the local official language)

My functional and identity needs

Note: You don't tick the boxes if they're not appropriate for you.

Functional / Identity Flags I would like my carers to be aware of my concerns around:

  • Vision SCT 397540003
  • Hearing / Listening SCT 15188001
  • Cognition / thinking / understanding / information processing SCT 386806002
  • Speaking / communicating / Conversation / Verbal interactions SCT 29164008
  • Mobility / moving myself around SCT 82971005
  • Use of gender specific areas SCT 93461009
  • Memory SCT 386807006
  • Past Trauma SCT 161472001
  • Staying focused / Concentration SCT 1144748009
  • Managing my addiction(s) SCT 32709003

I am from a small and/or remote community and cities and/or lots of people are an unfamiliar environment for me. SCT 5794003

I may need help with

  • Eating / Drinking SCT 110292000
  • Toileting SCT 284911003
  • Getting out of bed SCT 301666002
  • Moving in bed SCT 301685004
  • Getting orientated in a new environment SCT 72440003
  • Dressing SCT 284977008
  • Bathing / Cleaning SCT 284807005
  • Taking my medications SCT 715037005
  • Reading Documentation SCT 309253009

I have:

  • A Guide Dog SCT 105506000
  • A Wheelchair SCT 105503008
  • A Communication Device SCT 719369003

Notes: other possible candidates = Hearing aid or cochlear implant, Walking stick, Prosthetic leg (….this list goes on and on)?

Anything else you want to say about your general care needs or anxieties, or to explain any of the boxes you ticked above:

Body Parts Census

Due to congenital birth variations, accidents or medical treatment, you might be missing organs or limbs that might impact your treatment or care, or have replacements.

OrganStatus
Arm L:
R:
SCT 368208006 / 368209003
Hand L:
R: 		SCT 85151006 / 78791008
Fingers L:
R: 		SCT 786841006 / 786842004
Leg L:
R: 		SCT 48979004 / 32696007
Calf L:
R: 		SCT 48979004 / 32696007
Foot L:
R: 		SCT 22335008 / 7769000
Toe L:
R: 		SCT 785708006 / 785709003
Hip L:
R: 		SCT 32709003
Eye L:
R: 		SCT 32709003
Hypothalamus SCT 67923007
Pituitary SCT 181125003
Tongue SCT 32709003
Jaw SCT 661005
Oesophagus SCT 32849002
Large Colon SCT 71854001
Stomach SCT 69695003
Gall Bladder SCT 28231008
Kidney L:
R: 		SCT 18639004 / 9846003
Liver SCT 10200004
Bladder SCT 89837001
Lung L:
R: 		SCT 44029006 / 3341006
Breasts L:
R: 		SCT 80248007 / 73056007
Ovary L:
R: 		SCT 43981004 / 20837000
Uterus SCT 35039007
Cervix SCT 71252005
Vagina SCT 76784001
Penis SCT 18911002
Prostate SCT 41216001
Testis L:
R: 		SCT 40689003

Format: (for techies)

Note: the server that processes this form does not store any information from the form, but in general, this form is intended for test data, not real protected health PHI.