Facility Staff Medical Record Abstraction

Medical Monitoring Project

Attachment6b_SPIF

Facility Staff Medical Record Abstraction

OMB: 0920-0740

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Attachment 6b


Surveillance Period Inpatient Form

OMB NO: 0920-0740

EXPIRATION DATE: 06/30/2010







Medical Monitoring Project (MMP)

Medical Record Abstraction Form

2008 Surveillance Period Inpatient Form (SPIF)

VERSION 3.0.0



Public reporting burden of this collection of information is estimated to average 3 minutes per patient record pulled, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0011). Do not send the completed form to this address.




O PTIONAL- FOR LOCAL USE ONLY

MMP SPIF v3.0.0


MMP Participant ID:



Date of Admission: Date not documented


A bstraction

Facility ID:




(ID of facility where abstraction is being conducted)







Inpatient medical record number:


Medical record number not documented




Patient name:


Patient residence:



Street:



City/County: State:


ZIP code:





Physician name:






DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control & Prevention


M edical Monitoring Project (MMP)

Medical Record Abstraction Form

2008 Surveillance Period Inpatient Form (SPIF)

v3.0.0


I. ABSTRACTION AND IDENTIFICATION












MMP Participant ID:


Surveillance Period (SP)


SP start date:



(12 months prior to date of interview OR 1st contact

attempt if no interview obtained)



SP end date:



(date of interview OR 1st contact attempt if no

interview obtained)










Date of abstraction:


Abstractor ID:
















Date of admission:

Date not documented

















Date of discharge:

Date not documented



Abstraction

Facility ID:


(ID of facility where abstraction is being conducted)




Was the documented care abstracted with this form given at another facility (i.e., outside the

Abstraction Facility)?





Yes

Complete information about the “Care” Facility


Enter Care Facility ID or indicate that Care Facility was not documented or was outside jurisdiction


Care

Facility ID



(ID of the facility where the documented care was provided)







No

Continue to Section II below


Care Facility not documented or outside jurisdiction

II. SURVEILLANCE PERIOD INPATIENT FORM SECTIONS – OPTIONAL


Is there documentation of any of the following during this inpatient stay?

Yes Select all that are documented below.

No This form is now complete except for optional section VIII (Remarks).


New or existing diagnoses of AIDS defining Opportunistic Illnesses

(AIDS OI)

Complete section III.



Prescription or continuation of medications other than ART

Complete section VI.


New or existing diagnoses of conditions other than AIDS OI

Complete section IV.


Laboratory test results, closest to admission

Complete section VII.

Prescription or continuation of antiretroviral therapy (ART) closest

to admission

Complete section V.



Laboratory test results, closest to discharge

Complete section VII.


Prescription or continuation of antiretroviral therapy (ART) closest

to discharge

Complete section V.



Laboratory test results, hepatitis screening tests

Complete section VII.


III. AIDS DEFINING OPPORTUNISTIC ILLNESSES (AIDS OI)


Is there documentation any new or existing diagnoses of AIDS defining opportunistic illnesses (AIDS OI) during this inpatient stay?

Yes Select all that are documented below.

No



1 Candidiasis, bronchi, trachea, or lungs



14 Lymphoma, Burkitt’s (or equivalent term)


2 Candidiasis, esophageal



15 Lymphoma, immunoblastic (IBL, or equivalent term)



3 Carcinoma, invasive cervical



16 Lymphoma, primary in brain


4 Coccidioidomycosis, disseminated or extrapulmonary


17 Mycobacterium avium complex or M. kansasii, disseminated or

extrapulmonary



5 Cryptococcosis, extrapulmonary



18 M. tuberculosis, pulmonary



6 Cryptosporidiosis, chronic intestinal (>1 month duration)



19 M. tuberculosis, disseminated or extrapulmonary


7 Cytomegalovirus disease (other than in liver, spleen, or nodes)


20 Mycobacterium, of other species or unidentified species,

disseminated or extrapulmonary



8 Cytomegalovirus retinitis (with loss of vision)



21 Pneumocystis jiroveci pneumonia (PCP)



9 Herpes simplex: chronic ulcer (>1 month duration) or

bronchitis, pneumonitis, or esophagitis




22 Pneumonia, recurrent in 12 month period



10 HIV encephalopathy


23 Progressive multifocal leukoencephalopathy (PML)



11 Histoplasmosis, disseminated or extrapulmonary



24 Salmonella septicemia, recurrent



12 Isosporiasis, chronic intestinal (>1 month duration)



25 Toxoplasmosis of brain



13 Kaposi’s sarcoma



26 Wasting syndrome due to HIV

IV. CONDITIONS OTHER THAN AIDS OI


Is there documentation of any new or existing diagnoses of conditions other than AIDS OI during this inpatient stay?

Yes Select all that are documented below.

No


1 Abscess



19 Erythema multiforme


37 Hypogonadism (gonadal

deficiency)



55 Prostatitis


2 Alcoholism


20 Erythroderma


38 Hypothyroidism


56 Psoriasis


3 Anxiety disorder



21 Fatty liver




39 Ischemic heart disease


57 Psychosis, including

schizophrenia


4 Arthritis (osteoarthritis)


22 Fever, unexplained,

>100F for 2+ weeks*



40 Lactic acidosis



58 Pulmonary hypertension


5 Asthma


23 Gastroesophageal reflux

disease (GERD)



41 Lipoatrophy



59 Rash, drug-related


6 Avascular necrosis


24 Guillain-Barré syndrome


42 Lipodystrophy


60 Renal failure


7 Buffalo hump


25 Hearing loss, acquired


43 Malignancy


61 Respiratory infection, upper


8 Bronchitis


26 Hepatic (liver) failure


44 Metabolic syndrome

62 Respiratory infection, NOS


9 Cardiomyopathy, due to

HIV or unknown cause


27 Hepatitis, alcohol-induced


45 Myelopathy (spinal cord

disease/disorder)



63 Seborrheic dermatitis


10 Cellulitis (skin infection,

bacterial)


28 Hepatitis, drug-induced


46 Myopathy (muscular

weakness or changes)


64 Stevens-Johnson

Syndrome


11 Depression, diagnosed by

physician


29 Hepatitis, infectious, not

drug-induced


47 Nephrolithiasis (kidney

stone)



65 Stroke, ischemic, non-

hemorrhagic


12 Diabetes mellitus (DM),

type 1



30 Hepatitis, NOS


48 Nephropathy (kidney

damage)



66 Suicide attempt


13 Diabetes mellitus (DM),

type 2


31 Hodgkin’s lymphoma

(Hodgkin’s disease)


49 Neuropathy, cranial


67 Thrombocytopenia,

idiopathic (ITP)



14 Diabetes mellitus (DM), NOS


32 Human papillomavirus

(HPV) infection



50 Neuropathy, peripheral


68 Vision loss, moderate or

severe; blindness



15 Diarrhea, allergic/colitis




33 Hypercholesterolemia



51 Neuropathy, NOS



69 Warts, anal or genital



16 Diarrhea, infectious



34 Hyperglycemia


52 Oral candidiasis (thrush)


70 Warts, non-anal, non-

genital



17 Diarrhea, NOS


35 Hypertension (high blood

pressure)


53 Osteopenia or

osteoporosis

*in absence of a known cause


18 Erectile dysfunction


36 Hypertriglyceridemia


54 Pneumonia



IV. CONDITIONS OTHER THAN AIDS OI cont’d




71 Other, specify:




72 Other, specify:




73 Other, specify:



74 Other, specify:




75 Other, specify:





76 Other, specify:




77 Other, specify:

V. ANTIRETROVIRAL THERAPY (ART)





Is there documentation of prescription of antiretroviral therapy (ART) during this inpatient stay?

Yes Select all that are documented below.

No

Prescription or continuation

closest to:


Admission

Discharge

Name

Abbreviation

Also Known As

Group


1


1

Abacavir

ABC

Ziagen

NRTI


2


2

Amprenavir

APV

Agenerase

PI


3


3

Atazanavir

ATV

Reyataz

PI


4


4

Atripla

EFV/FTC/TDF


Multi-class


5


5

Combivir

AZT/3TC


CNRTI


6


6

Darunavir

DRV, TMC 114

Prezista

PI


7


7

Delavirdine

DLV

Rescriptor

NNRTI


8


8

Didanosine

Ddl

Videx

NRTI


9


9

Efavirenz

EFV

Sustiva

NNRTI


10


10

Emtricitabine

FTC

Emtriva

NRTI


11


11

Enfuvirtide

ENF, T-20

Fuzeon

FI


12


12

Epzicom

ABC/3TC


CNRTI


13


13


Etravirine (formerly TMC125)

ETR

Intelence

NNRTI


14


14

Fosamprenavir

FPV

Lexiva

PI


15


15

Indinavir

IDV

Crixivan

PI


16


16

Lamivudine

3TC

Epivir

NRTI


17


17

Lopinavir/Ritonavir

LPV/RTV

Kaletra, Meltrex

CNRTI



18



18

Maraviroc

MRC

Selzentry

Entry inhibitor



19



19

Nelfinavir

NFV

Viracept

PI


20


20

Nevirapine

NVP

Viramune

NNRTI



21



21

Raltegravir (formerly MK-0518)

RAL

Isentress

Integrase inhibitor


22


22

Ritonavir

RTV

Norvir

PI


23


23

Saquinavir

SQV-HGC

Invirase, Fortovase

PI


24


24

Stavudine

d4T

Zerit

NRTI


25


25

Tenofovir

TDF

Viread

NRTI


26


26

Tipranavir

TPV

Aptivus

PI


27


27

Trizivir

ABC/3TC/AZT


CNRTI


28


28

Truvada

FTC/TDF


CNRTI


V. ANTIRETROVIRAL THERAPY (ART) cont’d

Prescription or continuation

closest to:


Admission

Discharge

Name

Abbreviation

Also Known As

Group


29


29

Zalcitabine

ddC

Hivid

NRTI


30


30

Zidovudine

AZT

Retrovir

NRTI


31


31



Other, Specify:



32



32



Other, Specify:



33



33



Other, Specify:

VI. OTHER MEDICATIONS


Is there documentation of prescription or continuation of medications other than ART during this inpatient stay?

Yes Select all that are documented below.

No


1

acarbose


35

dapsone (DDS)


2

acetominophen/hydrocodone


36

darifenacin


3

acetominophen/oxycodone


37

dexamethasone


4

acyclovir


38

diphenhydramine


5

adefovir


39


doxorubicin


6

albuterol


40

doxorubicin lipsomal


7

albuterol/ipratropium


41

doxycycline


8

aldesleukin


42

dronabinol


9

alprazolam


43

enalapril


10

amikacin


44

enalapril/hydrochlorothiazide (HCTZ)


11

amitriptyline


45

entecavir


12

amitriptyline/chlordiazepoxide


46

epoetin alfa (EPO)


13

amoxicillin


47

escitalopram


14

amoxicillin/clavulanate


48

esomeprazole


15


aspirin (ASA)


49

ethambutol


16

atenolol


50

ethionamide


17

atorvastatin


51

famotidine


18

azithromycin


52

fexofenadine


19

baclofen


53

filgrastim


20

bupropion


54

folinic acid


21

buspirone


55

fluconazole


22

butalbital/aspirin


56

fludrocortisone


23

butalbital/aspirin/caffeine (BAC)


57

fluoxetine


24

calcitrol


58

fluphenazine


25

capreomycin


59

fluticasone


26

cetirizine


60

fluticasone/salmeterol


27

chlorpropamide


61

fluvastatin


28

cimetidine


62

foscarnet


29

ciprofloxacin


63

gabapentin


30

citalopram


64

gatifloxacin


31

clonazepam


65

gemfibrozil


32

cromolyn


66

hydrochlorothiazide (HCTZ)


33

cycloserine


67

hydrochlorothiazide (HCTZ)/methyldopa


34

cyclosporine


68

hydrochlorothiazide (HCTZ)/metoprolol


VI. OTHER MEDICATIONS cont’d


69

hydrochlorothiazide (HCTZ)/triamterene


108

penicillin


70


imiquimod


109


phenytoin


71

insulin (inhaled or injectable)


110

pioglitazone


72

interferon alphacon-1


111

podofilox topical


73

interferon alfa 2a


112

podophyllin topical


74

interferon alfa 2b


113

pravastatin


75

iodoquinol


114

prednisone


76

isoniazid (INH)


115

propranolol


77

isoniazid (INH)/pyrazinamide (PZA)/rifampin


116

propranolol/hydrochlorothiazide (HCTZ)


78

isoniazid (INH)/rifampin


117


pyrazinamide (PZA)


79

kanamycin


118

ranitidine


80

lansoprazole


119

ribavirin


81

lansoprazole/amoxicillin/clarithromycin


120

rifabutin


82

levofloxacin


121

rifampin


83

levothyroxine


122

rifapentine


84

lisinopril


123

rosiglitazone


85

lithium


124

rosiglitazone/glemepiride


86

loxapine


125

rosuvastatin


87

megestrol


126

sertraline


88

metformin


127

sildenafil


89

methadone


128

somatropin


90

metoclopramide


129

streptomycin


91

metoprolol


130

tadalafil


92

mirtazapine


131

tamsulosin


93

moxifloxacin


132

telbivudine


94

nalbuphine


133

testosterone


95


niacin


134

tinidazole


96

nifedipine


135

trazadone


97

nizatidine


136

triamcinolone nasal


98

octreotide


137

trichloracetic acid (TCA) topical


99

olanzapine


138

trimethoprim/sulfamethoxazole (TMP/SMZ)


100

omeprazole


139

valacyclovir


101

oxycodone


140

valproic acid


102

p-aminosalicylate


141

vancomycin


103

palonosetron


142

vardenafil


104

pantoprazole


143

venlafaxine


105

paroxetine


144

warfarin


106

peginterferon alfa 2a


145

zanamivir


107

peginterferon alfa 2b


146

zolpidem


147 Other,

Specify:


148 Other,

Specify:


149 Other,

Specify:


150 Other,

Specify:


151 Other,

Specify:


VII. INPATIENT LABORATORY TEST RESULTS


Is there documentation of any of the following laboratory test results during this inpatient stay?

Yes Enter all that are documented for each test below.

No


Laboratory tests performed closest to admission: (select all that are documented)



Result


Undetectable

Value

Units (select one, where applicable)


1 CD4 cell count




Cells/ mm3 or µL


Other, specify: ___________________________


Units not

documented


2 CD4 cell %




%



3 HIV viral load




Copies/mL


Other, specify: ___________________________


Units not

documented


Lower Limit of Detection for HIV Viral Load Test Used:

Lower Limit of Detection NOT documented



4 ALT (SGPT)




Units /L


Other, specify: ___________________________


Units not

documented


5 AST (SGOT)




Units/L


Other, specify: ___________________________



Units not

documented


6 Creatinine

(Creat, Cr)




mg/dL


Other, specify: ___________________________



Units not

documented


Laboratory tests performed closest to discharge: (select all that are documented)




Result


Undetectable

Value

Units (select one, where applicable)


1 CD4 cell count




Cells/ mm3 or µL


Other, specify: ___________________________


Units not

documented


2 CD4 cell %




%



3 HIV viral load




Copies/mL


Other, specify: ___________________________


Units not

documented


Lower Limit of Detection for HIV Viral Load Test Used:

Lower Limit of Detection NOT documented



4 ALT (SGPT)




Units /L


Other, specify: ___________________________


Units not

documented


5 AST (SGOT)




Units/L


Other, specify: ___________________________



Units not

documented


6 Creatinine

(Creat, Cr)




mg/dL


Other, specify: ___________________________



Units not

documented


INFECTIOUS DISEASE TESTS: Hepatitis A, B, C

Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


22 Anti-HAV IgG

(HAV Ab IgG)







23 Anti-HAV IgM

(HAV Ab IgM)







24 Anti-HAV total

(HAV Ab total)







VII. INPATIENT LABORATORY TEST RESULTS cont’d

Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


25 Anti-HBc IgG

(HBc Ab IgG)







26 Anti-HBc IgM

(HBc Ab IgM)







27 Anti-HBc total

(HBc Ab total)







28 Anti-HBe (HBe Ab)







29 Anti-HBs IgG

(HBs IgG Ab)








30 Anti-HBs total

(HBs Ab)








31 HBeAg

(Hepatitis B e-antigen)







32 HBsAg

(Hepatitis B surface antigen)







33 HBV DNA (PCR)



IU/mL


Other, specify: _______________________


Units not

documented


Lower Limit of Detection for HBV DNA (PCR) Test Used:



Lower Limit of detection NOT documented


Pos(+)

Neg(-)

Indeterminate

Undetectable

Value

Units (select one, where applicable)


34 Anti-HCV, EIA

or RIBA







35 HCV genotype










36 HCV RNA

qualitative






37 HCV RNA

quantitative (PCR)





IU/mL


Other, specify: _______________________


Units not

documented


Lower Limit of Detection for HCV RNA (PCR) Test Used:


Lower Limit of Detection NOT documented







MMP SPIF v3.0.0

Abstraction


MMP Participant ID: Facility ID:


(ID of facility where abstraction is being conducted)



Date of Admission:

Mo. Day Year



VIII. REMARKS














































Page 17 of 17

OMB 0920-0740 - Surveillance Period Inpatient Form – 6/2010

File Typeapplication/msword
File TitleMedical monitoring project (MMP)
AuthorRita Morgan
Last Modified Byziy6
File Modified2009-02-26
File Created2009-02-26

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