ATTACHMENT F
Medical Records Data Abstraction Form
Person retrieving information:
Name of hospital/clinic:
Time period covered: (mm-yyyy to mm-yyyy)
SECTION A- NEUROSURGERY
Lesion
A1.
Date of lesion closure: _____________________ Information not in medical records
(mm-dd-yyyy)
A2.
Level of lesion reported: ____________________ Information not in medical records
Shunt
A3.
Hydrocephalus present?
Yes
No SKIP A4-A16
Information not in medical records
A4.
Shunt present?
Yes
No SKIP A5-A16
Information not in medical records
A5.
What date was the shunt inserted (mm-dd-yyyy)
Information not in medical records
A6.
What type of shunt? CHECK ALL THAT APPLY
Ventriculoatrial shunt
Ventriculo-subgaleal shunt (this shunt is used temporarily)
Ventriculo-peritoneal shunt
Other, specify
Information not in medical record
A7.
Has shunt revision/s been performed?
Yes
No SKIP A8-A16
Information not in medical records
Shunt Revision
Shunt Obstruction
A8.
Was the shunt obstructed?
Yes_______________ (mm-dd-yyyy)
No SKIP A9-A10
Information not in medical records
A9.
Was the shunt revised?
Yes
No SKIP A10
Information not in medical records
A10.
What date was shunt reinserted (mm-dd-yyyy)
Information not in medical records
Shunt Infection
A11.
Was the shunt infected?
Yes_______________ (mm-dd-yyyy)
No SKIP A12-A13
Information not in medical records
A12.
What was the culture result? Write type of organism
Information not in medical records
For office use only A13.
Gramm Negative
Not Gramm Negative
Not enough information to determine what type of organism
Information not in medical records
A14.
Was the shunt removed and then reinserted?
Yes
No SKIP A15
Information not in medical records
A15.
What date/s removed and reinserted? ________ (mm-dd-yyyy)
A16.
Total number of shunt revisions _____________________
COLLECT INFORMATION FOR EACH SHUNT REVISION. IF MORE THAN ONE USE ADDITIONAL FORM (I.E., COPY OF SAME FORM)
Tethered Cord
A17.
Tethered spinal cord diagnosed?
Yes, what date _______________________ (mm-dd-yyyy)
No SKIP A18-A19
Information not in medical records
A18.
Surgery related to tethered cord?
Yes, specify type of surgery and date below
________________________________________ Type of surgery (mm-dd-yyyy)
________________________________________ Type of surgery (mm-dd-yyyy)
________________________________________ Type of surgery (mm-dd-yyyy)
________________________________________ Type of surgery (mm-dd-yyyy)
________________________________________ Type of surgery (mm-dd-yyyy)
________________________________________ Type of surgery (mm-dd-yyyy)
No SKIP A19
Information not in medical records
A19.
Total number of tethered cord related surgeries________________________
Symptomatic Chiari II Malformation
A20.
Symptomatic Chiari II malformation diagnosed?
Yes, what date _______________________ (mm-dd-yyyy)
No SKIP A21-A23
Information not in medical records
A21.
Presenting symptoms of Chiari II Malformation- check all that apply
Difficulty feeding
Aspiration
Gagging problems
Weak cry
Arm weakness
Spacticity
High pitched cry
Temporary stridor (noisy breathing)
Apnea
Cyanosis
Other, specify
Information not in medical records
A22.
Has Chiari decompression, or any other surgery related to Chiari II malformation been performed?
Yes, specify type of surgery and date below
1) ________________________________________ (type of surgery)
________________________________________ (mm-dd-yyyy)
2) ________________________________________ (type of surgery)
________________________________________ (mm-dd-yyyy)
3) ________________________________________ (type of surgery)
________________________________________ (mm-dd-yyyy)
No SKIP A23
Information not in medical records
A23.
Total number of Chiari II malformation related surgeries
Procedures Performed
A24.
MRI performed?
Yes
No SKIP A25-A28
Information not in medical records
A25.
Date of MRI ______________________________ (mm-dd-yyyy)
A26.
MRI performed on what area?
Head/neck
Spine
Other, specify________________________________________
Information not in medical records
A27.
MRI findings?
Chiari II malformation
Syrinx (syringomyelia)
Syringobulbia
Diastematomyelia
Other, specify________________________________________
A28.
Total number of MRIs performed ________________________
COLLECT INFORMATION FOR EACH MRI. IF MORE THAN ONE USE ADDITIONAL FORM (I.E., COPY OF SAME FORM)
A29.
CT scan performed to ventricles?
Yes
No SKIP A30-A33
Information not in medical records
A30.
Date of CT scan________________ (mm-dd-yyyy)
A31.
CT scan performed on what area?
Head/neck
Spine
Other, specify_______________________________________
Information not in medical records
A32.
CT findings: ________________________________________________________________________________________________________________________________________________
A33.
Total number of CT scans performed______________________________
COLLECT INFORMATION FOR EACH CT SCAN. IF MORE THAN ONE USE ADDITIONAL FORM (I.E., COPY OF SAME FORM)
A34.
Notes/Comments Related to Neurosurgery:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SECTION B - UROLOGY, BLADDER & BOWEL MANAGEMENT
B1. Level of lesion reported: _______________ Information not in medical records
Bladder Anatomy & Function
B2.
What is the anatomy of the bladder?
Normal anatomy
Vesicostomy, specify date________________ (mm-dd-yyyy)
Other, please specify
______________________________________________________________________________________________________________________________________________________________________________________________________
Information not in medical records
Urodynamic Assessment
B3.
Has a urodynamic study been performed?
Yes
No SKIP B4-B7
Information not in medical records
B4.
Date
of urodynamic study: ________________ (mm-dd-yyyy)
B5.
Findings of urodynamic study (check all that apply):
Good compliance
Poor compliance
Over-activity
Leak point pressure greater than 40
Incontinent/leaking
Detrusor sphincter dyssenergia
Information not in medical records
B6.
Bladder capacity as % of predicted capacity ______________
Information not in medical records
B7.
Total number of urodynamic studies _____________________
COLLECT INFORMATION FOR EACH URODYNAMIC STUDY. IF MORE THAN ONE, USE ADDITIONAL FORM (I.E., COPY OF SAME FORM)
Kidney Anatomy
B8.
Kidney abnormalities noted?
Yes, ______________ (mm-dd-yyyy)
Specify
No
Information not in medical records
Urinary Tract Conditions
B9.
Diagnosis of urinary tract infection (UTI)?
Yes, ______________ (mm-dd-yyyy)
No SKIP B10-B13
Information not in medical records or “None noted”
B10.
Type of organism _________________________________
Information not in medical records
B11.
Who made the diagnosis?
Pediatric urologist
Pediatrician
Primary care physician
Emergency room physician
Other, specify____________________________________________________
Information not in medical records
B12.
What symptoms were present? (check all that apply)
Fever greater than 101degrees
Nausea/vomiting
Headaches
Fatigue/malaise
Change in cathing schedule
Change in voiding pattern
Foul smelling urine
Other, specify____________________________________________________
Information not in medical records
B13.
Total number of urinary tract infections _____________________
COLLECT INFORMATION FOR EACH URINARY TRACT INFECTION. IF MORE THAN ONE USE ADDITIONAL FORM (I.E., COPY OF SAME FORM)
B14.
Diagnosis of vesicoureteral reflux (VUR)?
Yes, ______________ (mm-dd-yyyy)
No SKIP B15-B20
Information not in medical records
B15.
Was the vesicoureteral reflux
Bilateral
Unilateral
Information not in medical records
B16.
Was a voiding cysto-urethrogram (VCUG) performed?
Yes, ______________ (mm-dd-yyyy)
No SKIP B17
Information not in medical records
B17.
Was the bladder neck
Open
Closed
Information not in medical records
B18.
What was the voided residual amount? ___________ Information not in medical records
B19.
What was the reflux grade on the right side?
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Information not in medical records
B20.
What was the reflux grade on the left side?
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Information not in medical records
Procedures
B21.
Have there been any surgeries related to urology?
Yes
No SKIP B22
Information not in medical records
B22.
Type of surgery (note multiple dates if applicable)
Bladder Augmentation ________________ (mm-dd-yyyy)
What type of bladder augmentation?
Colon
Ileocytoplasty
Ureter
Stomach
Other, specify_______________________________________
Information not in medical records
Mitrofanoff ________________ (mm-dd-yyyy)
Vesicostomy ________________ (mm-dd-yyyy)
Reimplant Ureter(s) ________________ (mm-dd-yyyy)
____________________ (mm-dd-yyyy)
Sphincter Tightening ________________ (mm-dd-yyyy)
________________ (mm-dd-yyyy)
Other Urologic Surgery ________________ (mm-dd-yyyy)
Specify___________________________________________________________________________________________________________________________________________________________
Imaging
B23.
Has imaging been performed?
Yes
No SKIP B24-B29
Information not in medical records
B24.
Date of imaging: ________________ (mm-dd-yyyy)
B25.
Ultrasonography
Nuclear imaging
Dimercaptosuccinic acid scintigraphy (DMSA)
Magnetic Resonance Imaging (MRI)
Other, specify
Information not in medical records
B26.
What area was x-rayed?
Bladder
Kidney
Ureter
Other, specify
Information not in medical records
Imaging Results
B27.
Kidney/s
Hydronephrosis
Normal size for age
Scarring
Other, specify
Information not in medical records
B28.
Bladder
Thick wall
Trabeculated
Other, specify
Information not in medical records
B29.
Total number of times for urology related imaging _____________________
COLLECT INFORMATION FOR EACH IMAGE. IF MORE THAN ONE USE ADDITIONAL FORM (I.E., COPY OF SAME FORM)
B30.
Has serum creatinine been measured?
Yes
No SKIP B31-B32
Information not in medical records
B31.
Date of serum creatinine: ________________ (mm-dd-yyyy)
B32.
Serum creatinine value: Level __________________________
Normal
Abnormal
Information not in medical records
Continence
Urinary
B33.
Does child wear diapers?
Yes
No
Information not in medical records
B34.
Is the child continent (without diapers)?
Continence defined as “Dry, with or without interventions during the day”
Yes
No
Information not in medical records
B35.
Does child use bladder management?
Yes
No SKIP B36-B38
Information not in medical records
B36.
What type of bladder management is/are being used? (check all that apply)
Normal void
Clean Intermittent Catheterization (CIC)
Dribble
Crede
Indwelling catheter
Other, specify _____________________________
Information not in medical records
B37.
What date was the child/family introduced to a bladder management program/s?
Date introduced ________________ (mm-dd-yyyy)
Information not in medical records
Type of bladder management
B38.
Who is primarily responsible for the bladder management program?
Child only
At what age did child start performing bladder management program
independently?
Information not in medical records
Caregiver
Other/s
Primarily the child, but others also
Does not apply
Information not in medical records
Continence
Bowel
B39.
Is the child continent and not using a diaper (i.e., no accidents)?
Yes
No SKIP B40-B41
Information not in medical records
B40.
What type of bowel management is being used (check all that apply)?
None, voluntary control (normal)
Involuntary, use diaper or pad
Regular scheduled bowel movements with aids used (enemas, digital
stimulation, suppositories, etc.)
Regular scheduled bowel movements with no aids used
Percutaneous Cecostomy or colostomy
Other, specify
Information not in medical records
B41.
Who is primarily responsible for the bowel management program?
Child only,
At what age did child start performing bowel management program
independently?
Information not in medical records
Caregiver
Other/s
Primarily the child, but others also
Does not apply
Information not in medical records
B42. Notes/Comments Related to Urology:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SECTION C: ORTHOPEDICS & MOBILITY
Overall Functioning & Mobility
C1. Level of lesion reported: ____________________
Information not in medical records
C2.
At what age did the child start to cruise? ________________ (give date if available)
Child did not cruise
Information not in medical records
C3.
At what age did the child start to sit? _________________ (give date if available)
Child did not sit
Information not in medical records
C4.
At what age did the child start to walk? __________________ (give date if available)
Child does not walk
Information not in medical records
C5.
What is the child’s mobility status? check all that apply
Full-time Independent
with assistive device
without assistive device
Household ambulator
Non-functional ambulator
Non-ambulators
Information not in medical records
Information regarding the child’s mobility status does not comply with the Hoffer classification used above. Please write down the information related to the child’s mobility status that is noted in the child’s record:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C6. Does the child use assistive technology?
Yes
No SKIP C7
Information not in medical records
C7. What assistive technology does the child use? check all that apply
Standing frame/wheeled stander
Reciprocating Gait Orthosis (RGO)
Hip-knee-ankle-foot-orthosis (HKAFO)
Knee-ankle-foot-orthosis (KAFO)
Ankle Foot Orthosis (AFO)
Walker, specify type of walker_________________________
forward/reversed
reversed K-walker
wheeled
unwheeled
Crutches, specify type of walker________________________
Other/s, please specify ________________________________
Information not in medical records
Conditions & Procedures
C8.
Diagnosis of scoliosis?
Yes, date of diagnosis _______________________ (mm-dd-yyyy)
No SKIP C9-C14
Information not in medical records
C9. How was the scoliosis diagnosis made?
Diagnosis made clinically
Diagnosis made radiographically
Information not in medical records
C10. Was the scoliosis congenital?
Yes
No
Information not in medical records
C11. What was listed as the cause/s of the scoliosis?
Chiari II malformation
Tethered cord
Split cord malformation
Syrinx/syringomyelia
Other, specify______________________________________
Information not in medical records
C12. Has the scoliosis been surgically corrected?
Yes, ______________________ (mm-dd-yyyy)
No SKIP C13-C14
Information not in medical records
C13. Were there complications related to the surgery?
Yes
No SKIP C14
Information not in medical records
C14. What were the complications? check all that apply
Infection
Pseudoarthritis arthrosis
Neurological loss of function
Medical complications
Pulmonary complications
Cerebrospinal fluid leak (CSF)
Other, specify____________________________________
C15.
Diagnosis of kyphosis?
Yes, date of diagnosis _______________________ (mm-dd-yyyy)
No SKIP C16-C21
Information not in medical records
C16. How was the kyphosis diagnosis made?
Diagnosis made clinically
Diagnosis made radiographically
Information not in medical records
C17. Was the kyphosis congenital?
Yes
No
Information not in medical records
C18. What was listed as the cause/s of the kyphosis?
Chiari II malformation
Tethered cord
Split cord malformation
Syrinx/syringomyelia
Other, specify______________________________________
Information not in medical records
C19. Has the kyphosis been surgically corrected?
Yes, ______________________ (mm-dd-yyyy)
No SKIP C20-C21
Information not in medical records
C20. Were there complications related to the surgery?
Yes
No SKIP C21
Information not in medical records
C21. What were the complications? please check all that apply
Infection
Pseudoarthritis arthrosis
Neurological loss of function
Medical complications
Pulmonary complications
Cerebrospinal fluid leak (CSF)
Other, specify____________________________________
Information not in medical records
C22.
Diagnosis of hip dislocation?
Yes, date of diagnosis _______________________ (mm-dd-yyyy)
No SKIP C23-C27
Information not in medical records
C23. Was the hip dislocation
Unilateral
Bilateral
C24. Was the diagnosis of hip dislocation made clinically or radiographically?
Diagnosis made clinically
Diagnosis made radiographically
Information not in medical records
C25. Was the hip dislocation congenital?
Yes
No
Information not in medical records
C26. Was the hip dislocation treated?
Yes
No SKIP C27
Information not in medical records
C27. How was the hip dislocation treated?
Surgically
Non-surgically
Information not in medical records
Knee and Rotational Disorders
C28.
Diagnosis of foot or ankle deformities?
Yes, what date _______________________ (mm-dd-yyyy)
No SKIP C29
Information not in medical records
C29.
Have the foot or ankle deformities been surgically corrected?
Yes, what date/s _______________________ (mm-dd-yyyy)
No
Information not in medical records
SECTION D- HOSPITALIZATION
Neurosurgery
D1. Has the child ever been hospitalized because of neurological complications?
Yes
No SKIP D2-D7
Information not in medical records
D2. Dates of 1st hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D3. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
D4. Dates of 2nd hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D5. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
D6. Dates of 3rd hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D7. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
IF MORE THAN 3 HOSPITALIZATIONS USE ADDITIONAL FORM
Urology
D8. Has the child been hospitalized because of urological complications?
Yes
No SKIP D9-D14
Information not in medical records
D9. Dates of 1st hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D10. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
D11. Dates of 2nd hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D12. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
D13. Dates of 3rd hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D14. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
IF MORE THAN 3 HOSPITALIZATIONS USE ADDITIONAL FORM
Orthopedics
D15. Has the child been hospitalized because of complications related to orthopedics?
Yes
No SKIP D16-D21
Information not in medical records
D16. Dates of 1st hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D17. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
D18. Dates of 2nd hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D19. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
D20. Dates of 3rd hospitalization:___________________________________________
(mm-dd-yyyy) (mm-dd-yyyy)
D21. List reason/s for hospitalization?_________________________________________________________________________________________________________________________________________________________________________________________
IF MORE THAN 3 HOSPITALIZATIONS USE ADDITIONAL FORM
| File Type | application/msword |
| Author | sax3 |
| Last Modified By | sax3 |
| File Modified | 2008-08-06 |
| File Created | 2008-06-16 |