0920-0740 Surveill Surveillance Period Inpatient Form

Attachment 3d

MMP Medical Record Abstraction

Surveillance Period Inpatient Form

Medical Monitoring Project (MMP)

Medical Record Abstraction Form

2012 Surveillance Period Inpatient Form (SPIF)

VERSION 7.1.0

O PTIONAL- FOR LOCAL USE ONLY

MMP SPIF v7.1.0

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

2012 Surveillance Period Inpatient Form (SPIF)

V7.1.0

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, >100F 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 v7.1.0

Abstraction

MMP Participant ID: Facility ID:

(ID of facility where abstraction is being conducted)

Date of Admission:

^{Mo. Day Year}

VIII. REMARKS

Page 15 of 15

OMB 0920-0740 - Surveillance Period Inpatient Form –11/2011