Facility Staff Medical Record Abstraction

Medical Monitoring Project

Att_3a_MMP abstraction_MHF_v7 1 0

Facility Staff Medical Record Abstraction

OMB: 0920-0740

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Form Approved

OMB NO: 0920-0740

EXPIRATION DATE: 05/31/2012














Medical Monitoring Project (MMP)

Medical Record Abstraction Form

2012 Medical History Form (MHF)

VERSION 7.1.0












O PTIONAL- FOR LOCAL USE ONLY



M MP MHF v7.1.0

Abstraction

MMP Participant ID: Facility ID:

(ID of the facility where abstraction is being conducted)


Medical record number:




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 Medical History Form (MHF) 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)


Medical History Period (MHP)



MHP start date: (date of first HIV care (at any facility) documented in this medical record)





First visit to this facility: (date of first available visit to this facility for HIV care)





MHP end date: (day before the SP start date)

OR


No documented care in medical records prior to SP start date Complete sections I, II, and IX (documentation of the first positive

HIV test result)




Abstraction

Facility ID:


(ID of the facility where abstraction is being conducted)



For the medical history period

Abstract information on all HIV care documented in the medical records at the “Abstraction Facility” using a single MHF regardless of where the care was actually provided to the patient.



Date of abstraction: Abstractor ID:

Mo. Day Year

II. PATIENT DEMOGRAPHICS


Date of birth: Date not documented

Mo. Day Year






If date of birth is not documented, enter documented age:


Enter date of this documented age: Date not documented

Mo. Year

Age not documented


Most recent height (ft/in) prior to the SP start date:



Enter date of this documented height: Date not documented










ft. inches





Height not documented


Sex at birth: Male Not documented

(select one) Female


Gender: Male Male to female Not documented

(select one) Female Female to male



II. PATIENT DEMOGRAPHICS cont’d



Hispanic or Latino ethnicity: Yes, Hispanic or Latino Not documented

(select one) No, not Hispanic or Latino





Race: 1 American Indian or Alaska Native

(select all that are documented) 2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White






6 Not documented



Country of birth: 1 United States

(select one) 2 US Dependencies/Possessions (including Puerto Rico)

3 Other, Specify:­­­­


4 Not documented


III. MEDICAL HISTORY FORM SECTIONS - OPTIONAL



Is there documentation of any of the following prior to the SP start date?

Yes Select all that are documented below.

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





Diagnosis of AIDS defining opportunistic illnesses (AIDS OI)

Complete section IV.


First positive HIV test result, or laboratory test results for CD4

cell count, HIV viral load, or abnormal ALT (SGPT) or AST

(SGOT)

Complete section IX.


Prescription for prophylaxis of Pneumocystis jiroveci pneumonia

(PCP) or Mycobacterium avium complex (MAC)

Complete section V.



Testing for HIV ART resistance

Complete section X.


Screening for hepatitis (A, B, or C), Toxoplasma, or tuberculosis

(TB)

Complete section VI.


Reported or suspected substance abuse, including

substance abuse counseling or treatment

Complete section XI.


Whether or not hepatitis A, B, A and B, or pneumococcal

immunizations were given

Complete section VII.


Diagnosis of anxiety, bipolar disorder, psychosis, or

depression

Complete section XII.


Prescription of antiretroviral therapy (ART)

Complete section VIII.


IV. AIDS DEFINING OPPORTUNISTIC ILLNESSES (AIDS OI)


Is there documentation that any AIDS defining opportunistic illnesses (AIDS OI) were diagnosed prior to the SP start date?

Yes Enter all that are documented below.

No


AIDS defining opportunistic illnesses (AIDS OI)

prior to the SP start date

(select all that are documented and record dates)


Date of first diagnosis


Date

not

documented



1 Candidiasis, bronchi, trachea, or lungs




1



2 Candidiasis, esophageal



2



3 Carcinoma, invasive cervical



3


4 Coccidioidomycosis, disseminated or extrapulmonary



4



5 Cryptococcosis, extrapulmonary



5


IV. AIDS DEFINING OPPORTUNISTIC ILLNESSES (AIDS OI) cont’d

AIDS defining opportunistic illnesses (AIDS OI)

prior to the SP start date

(select all that are documented and record dates)


Date of first diagnosis


Date

not

documented



6 Cryptosporidiosis, chronic intestinal (>1 month duration)



6


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



7



8 Cytomegalovirus retinitis (with loss of vision)



8



9 HIV encephalopathy



9


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

bronchitis, pneumonitis, or esophagitis



10



11 Histoplasmosis, disseminated or extrapulmonary



11



12 Isosporiasis, chronic intestinal (>1 month duration)



12



13 Kaposi’s sarcoma



13



14 Lymphoma, Burkitt’s (or equivalent term)



14



15 Lymphoma, immunoblastic (IBL, or equivalent term)



15



16 Lymphoma, primary in brain



16


17 Mycobacterium avium complex or M. kansasii, disseminated or

Extrapulmonary



17



18 M. tuberculosis, pulmonary



18



19 M. tuberculosis, disseminated or extrapulmonary



19


20 Mycobacterium, of other species or unidentified species,

disseminated or extrapulmonary



20



21 Pneumocystis jiroveci pneumonia (PCP)



21



22 Pneumonia, recurrent in 12 month period



22


23 Progressive multifocal leukoencephalopathy (PML)



23



24 Salmonella septicemia, recurrent



24



25 Toxoplasmosis of brain



25



26 Wasting syndrome due to HIV



26

V. PROPHYLAXIS


Is there documentation of prescription for prophylaxis of Pneumocystis jiroveci pneumonia (PCP) prior to the SP start date?

Yes No


Prescription must be for PCP prophylaxis. Medications include:

Bactrim® (Septra, Cotrim, Co-trimoxazole, trimethorprim, sulfamethoxazole)

Dapsone®

Pentamidine® (pentamidine isothianate)

Mepron® or Mepron® Suspension (atovaquone)

Clindamycin® (clindamycin hydrochloride) + Primaquine® (primaquine phosphate)

Dapsone® + Daraprim® (pyrimethamine) + Folinic Acid



Is there documentation of prescription for prophylaxis of Mycobacterium avium complex (MAC) prior to the SP start date?

Yes No


Prescription must be for MAC prophylaxis. Medications include:

Biaxin Filmtab® (clarithromycin)

Biaxin Granules®

Biaxin XL®

Zithromax®

Zithromax Single Pack® (azithromycin, azithromycin dihydrate)

Mycobutin® (rifabutin)



VI. HEPATITIS, TOXOPLASMA, AND TUBERCULOSIS (TB) SCREENING

Is there documentation of screening for hepatitis A, B, C, Toxoplasma, or tuberculosis (TB) prior to the SP start date?

Yes Enter all that are documented for each screening below.

No



Was hepatitis A screening performed prior to the SP start date? (select one)

1 Yes – screening done Enter all that are documented for “Yes” below


2 No – documented that screening not done


3 Hepatitis A screening not documented


If “Yes,” what were the results?

Select all that apply OR result not documented



Positive

Date of 1st positive test:





Date not documented


Which Hepatitis A test(s) was/were positive on this date?

(select all that apply)


Anti HAV IgG or HAV Ab IgG Anti HAV total or HAV Ab total

Anti-HAV IgM or HAV Ab IgM Test type not documented



Negative



Date of last negative test:





Date not documented



Result not documented


Was hepatitis B screening performed prior to the SP start date? (select one)

1 Yes – screening done Enter all that are documented for “Yes” below


2 No – documented that screening not done


3 Hepatitis B screening not documented


If “Yes,” what were the results?

Select all that apply OR result not documented



Positive

Date of 1st positive test:





Date not documented


Which Hepatitis B test(s) was/were positive on this date? (select all that apply)


Anti HBc IgG Anti HBs IgG or HBsAb IgG


Anti HBc IgM Anti HBs or HBsAb total


Anti HBc total HBsAg


Test type not documented


Negative


Date of last negative test:





Date not documented



Result not documented



Was hepatitis C screening performed prior to the SP start date? (select one)

1 Yes – screening done Enter all that are documented for “Yes” below


2 No – documented that screening not done


3 Hepatitis C screening not documented


If “Yes,” what were the results?

Select all that apply OR result not documented


Positive

Date of 1st positive test:





Date not documented


Which Hepatitis C test(s) was/were positive on this date?

(select all that apply)



Anti HCV (EIA or RIBA) HCV RNA quantitative (PCR)

HCV RNA qualitative Test type not documented


Negative



Date of last negative test:





Date not documented



Result not documented


VI. HEPATITIS, TOXOPLASMA, AND TUBERCULOSIS (TB) SCREENING cont’d


Was Toxoplasma screening performed prior to the SP start date? (select one)

1 Yes – screening done Enter all that are documented below.

2 No – documented that screening not done


3 Toxoplasma screening not documented


Was there a positive result for the most recent Toxoplasma antibody titer prior to the SP start date? (select one)






1 Yes Enter date of positive result: Date not documented


2 No (negative result for most recent test)


3 Result not documented


Was screening for tuberculosis (TB) performed prior to the SP start date? (select one)


1 Yes – screening done Enter all that are documented below.

2 No – documented that screening not done


3 TB screening not documented



Date of the most recent tuberculin skin test (TST/PPD/Mantoux) or QuantiFERON test (QFT) prior to the SP start date:











Date not documented



Result of the most recent TST/PPD/Mantoux or QFT prior to the SP start date: (enter one for TST/PPD/Mantoux OR one for QFT)



TST/PPD/Mantoux: (enter OR select one)

Result in millimeters:

1 Positive, no value reported


2 Negative, no value reported


3 Not read


4 Anergic


5 Not documented


OR









QFT: (select one)


1 QFT positive


2 QFT negative


3 QFT indeterminate


4 Not documented

VII. HEPATITIS AND PNEUMOCOCCAL IMMUNIZATIONS


Is there documentation of whether or not hepatitis A, B, A and B, or pneumococcal immunizations were given prior to the SP start date?

Yes Enter all that are documented for each vaccine below.

No


Was hepatitis A vaccine (Havrix, Vaqta) given prior to the SP start date? (select one: Yes, No, or Not documented)



1 Yes




Enter a maximum of 3 documented doses and dates: Dose No.

(If documented) Date

Date not

documented


2 Yes – but number of doses not documented



_____









3 No – documented that vaccine not given


Reason vaccine not given: (select one)



_____








Prior vaccination



Patient declined



Previously infected


Not documented



Other, specify


_____











4 Hepatitis A vaccination not documented






VII. HEPATITIS AND PNEUMOCOCCAL IMMUNIZATIONS cont’d




Was hepatitis B vaccine (Energix B, Recombivax) given prior to the SP start date? (select one: Yes, No, or Not documented)





1 Yes



Enter a maximum of 4 documented doses and dates: Dose No.

(If documented) Date

Date not

documented



2 Yes – but number of doses not documented



_____









3 No – documented that vaccine not given




Reason vaccine not given: (select one)




_____










Prior vaccination



Patient declined




Previously infected


Not documented




Other, specify


_____











_____









4 Hepatitis B vaccination not documented







Was combination hepatitis A and B vaccine (Twinrix) given prior to the SP start date? (select one: Yes, No, or Not documented)






1 Yes



Enter a maximum of 4 documented doses and dates: Dose No.

(If documented) Date

Date not

documented



2 Yes – but number of doses not documented



_____








3 No – documented that vaccine not given



Reason vaccine not given: (select one)



_____









Prior vaccination



Patient declined




Previously infected


Not documented




Other, specify


_____













_____





4 Hepatitis A and B vaccination not documented








Was pneumococcal vaccine (Pneumovax 23, Pneu-Immune 23) given prior to the SP start date?

(select one Yes, No, or Not documented)





1 Yes



Enter date of last dose given before the SP start date:

Mo. Year

Date

Date not

documented




2 No – documented that vaccine not given






Reason vaccine not given: (select one)





Prior vaccination



Patient declined








Not documented




Other, specify










3 Pneumococcal vaccination not documented




VIII. ANTIRETROVIRAL THERAPY (ART)




Is there documentation of prescription of antiretroviral therapy (ART) prior to the SP start date?

Yes Enter all that that are documented below.

No



Date of first prescribed antiretroviral medication: Date not documented

Prescribed antiretroviral medications prior to the SP start date: (select all that are documented)



1 Abacavir (ABC, Ziagen)



9 Efavirenz (EFV, Sustiva)


17 Lopinavir/Ritonavir

(LPV/RTV, Kaletra, Meltrex)



25 Tenofovir (TDF, Viread)


2 Amprenavir (APV,

Agenerase)



10 Emtricitabine (FTC, Emtriva)



18 Maraviroc (MRC, Selzentry)


26 Tipranavir (TPV,

Aptivus)



3 Atazanavir (ATV, Reyataz)


11 Enfuvirtide (ENF, T-20,

Fuzeon)



19 Nelfinavir (NFV, Viracept)



27 Trizivir (ABC/3TC/AZT)


4 Atripla (EFV/FTC/TDF)


12 Epzicom (ABC/3TC)



20 Nevirapine (NVP, Viramune)


28 Truvada (FTC/TDF)



5 Combivir (AZT/3TC)


13 Etravirine (Intelence, ETR,

formerly TMC125)


21 Raltegravir (RAL, Isentress,

MK-0518)



29 Zalcitabine (ddC, Hivid)


6 Darunavir (DRV, TMC 114,

Prezista)

14 Fosamprenavir (FPV,

Lexiva)



22 Ritonavir (RTV, Norvir)


30 Zidovudine (AZT,

Retrovir)


7 Delavirdine (DLV,

Rescriptor)



15 Indinavir (IDV, Crixivan)


23 Saquinavir (SQV-HGC,

Invirase, Fortovase)



8 Didanosine (ddl) Videx



16 Lamivudine (3TC, Epivir)


24 Stavudine (d4T, Zerit)




31 Other,

Specify:



3 2 Other,

Specify:



3 3 Other,

Specify:



3 4 Other,

Specify:

IX. LABORATORY TEST RESULTS




Is there documentation of the first positive HIV test result, or laboratory test results for CD4 cell count, or HIV viral load, prior to the SP start date?

Yes Enter all that are documented for each diagnosis or test below.

No


Is there documentation of the first positive HIV test result?





Yes Enter date of first positive HIV test: Date not documented


No




Is there documentation of CD4 cell count test results prior to the SP start date?


Yes Lowest CD4 cell count: / µl or mm3


No



Date of lowest CD4 cell count: Date not documented



Is there documentation of HIV viral load (VL) test results prior to the SP start date?




Yes Is there documentation of an undetectable VL?



No





Yes Enter date of most recent undetectable result: Date not

No documented


X. HIV ART RESISTANCE TESTING


Is there documentation of HIV ART resistance testing prior to the SP start date?

Yes Select all that are documented for each resistance test below.

No


Was genotypic ART resistance testing performed prior to the SP start date?

(Select one: Yes, No, or Testing not documented)


Select all ART classes documented with resistance and/or possible resistance:


1 Yes – resistance reported

FI PI NRTI NNRTI ART classes not specified


2 Yes – possible resistance reported


FI PI NRTI NNRTI ART classes not specified


3 Yes – but no resistance reported



4 Yes – but result was indeterminate



5 Yes – but test result not documented


6 No – documented that genotypic resistance testing was not done


7 Genotypic resistance testing not documented


Was phenotypic ART resistance testing performed prior to the SP start date?

(Select one: Yes, No, or Testing not documented)



Select all ART classes documented with resistance and/or intermediate resistance:


1 Yes – resistance reported

FI PI NRTI NNRTI ART classes not specified


2 Yes – intermediate resistance reported


FI PI NRTI NNRTI ART classes not specified


3 Yes – but no resistance reported



4 Yes – but result was indeterminate



5 Yes – but test result not documented


6 No – documented that phenotypic resistance testing was not done


7 Phenotypic resistance testing not documented



Was virtual phenotypic ART resistance testing performed prior to the SP start date?

(Select one: Yes, No, or Testing not documented)


Select all ART classes documented with resistance and/or possible / intermediate resistance reported:


1 Yes – resistance reported

FI PI NRTI NNRTI ART classes not specified


2 Yes – possible/intermediate resistance reported


FI PI NRTI NNRTI ART classes not specified


3 Yes – but no resistance reported



4 Yes – but result was indeterminate



5 Yes – but test result not documented


6 No – documented that virtual phenotypic resistance testing was not done



7 Virtual phenotypic resistance testing not documented

XI. SUBSTANCE ABUSE


Is there documentation of reported or suspected alcohol abuse or other non-prescribed use of substances, including counseling or treatment for alcohol and/or substance use/abuse prior to the SP?

Yes Enter all that are documented below.

No


Alcohol Abuse


Is there documentation of alcohol abuse prior to the SP? Yes No


Other Non-prescribed Use of Substances


Is there evidence of any injection substance use (e.g., track marks) documented prior to the SP? Yes No



XI. SUBSTANCE ABUSE cont’d



Non-prescribed use of substances documented prior to the SP: (select all that are documented and type of use)





Substance

Type of Use

(select all that apply OR select Not documented)

Injection

Non-Injection

Not documented


1 Amphetamines (other than methamphetamines)








2 Cocaine (other than crack)








3 Crack cocaine








4 Ecstasy (MDMA, X)





5 GHB





6 Hallucinogens such as LSD or mushrooms





7 Heroin








8 Ketamine (Special K)





9 Marijuana





10 Methadone









11 Methamphetamines








12 Painkillers such as Oxycontin, Vicodin or Percocet








13 Poppers (amyl nitrate)





14 Rohypnol





15 Steroids/Hormones








16 Tranquilizers such as Valium, Ativan, or Xanax





17 Viagra, Levitra or Cialis





1 8 Other,

Specify:














1 9 Other,

Specify:














2 0 Other,

Specify:















21 Substance not specified







XII. MENTAL HEALTH



Is there documentation of any of the following mental illnesses prior to the SP start date?

Yes Select all that are documented below.

No



1

Anxiety disorder (General anxiety disorder, GAD)



3

Depression (Major depression, depressive disorder)



2

Bipolar disorder



4

Psychosis



O PTIONAL- FOR LOCAL USE ONLY

MMP MHF v7.1.0


Abstraction

MMP Participant ID: Facility ID:


(ID of the facility where abstraction is being conducted)


XIII. REMARKS















































Page 21 of 21

OMB 0920-0740 – Medical History Form - 11/2011


File Typeapplication/msword
File TitleMedical monitoring project (MMP)
AuthorRita Morgan
Last Modified ByBonds, Constance (CDC/OID/NCHHSTP)
File Modified2012-02-06
File Created2011-12-16

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