2 Acute Care Visit

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Sickle Cell Test Team 1
Page 1 of 3

Acute Care Visit (2012)
Participant ID

__________________________________
((do not change this value))

OMB Number (0915-XXXX) Expiration date (XX/XX/20XX)
Public Burden Statement: 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. The OMB control number for this
project is 0915-XXXX. Public reporting burden for this collection of information is estimated to average ____ hours per
response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane,
Room 10-29, Rockville, Maryland, 20857.
Team site:

Team 1 - Site A
Team 1 - Site B
Team 1 - Site C
Team 1 - Site D
Team 1 - Site E

Reviewer's initials:

__________________________________

Date of chart review:

__________________________________

Acute Care Visit Information
Date of visit:
Primary reason for visit

Specify
Is the patient less than one year old?

__________________________________
Pain
Fever
Fever and Pain
Other
__________________________________
Yes

No

Patient 's age in months (0 for under 1 month old):

__________________________________
(number between 0 and 11)

Patient's age in years:

__________________________________
(number )

Date/time of registration:

__________________________________
(registration refers to the time when the patient
gave their name and other personal/insurance
information to the registrar upon arrival to the
ED or infusion center/day hospital )

Date/time of triage:

__________________________________
(time when patient nurse provides brief, focused
assessment of chief complaint and vital signs and
assigns patient's acuity level)

Time from registration to triage:

__________________________________
(minutes)

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Fever Care
Maximum temperature on presentation or by history:
Was a broad spectrum IV antibiotic ordered?

__________________________________
(C)
Yes

No

Not available

Date/time of IV antibiotic order:

__________________________________
(leave blank if unknown)

Date/time of IV antibiotic administration:

__________________________________

Minutes to first antibiotic dose:

__________________________________
(minutes between triage and first antibiotic
administration)

Did the patient have a CBC drawn within 60 minutes of
registration?

Yes

No

Not available

Did the patient have a reticulocyte count drawn
within 60 minutes of registration?

Yes

No

Not available

Did the patient have blood culture sent within 60
minutes of registration?

Yes

No

Not available

Did the patient have pulse oximetry performed within
60 minutes of registration?

Yes

No

Not available

Yes

No

Not available

Pain Care
Was a quantitative pain assessment scale (0-10 scale)
used for pain assessment?
Date/Time of initial pain assessment:

__________________________________

Minutes between pain assessment and triage:

__________________________________

Did patient have moderate-severe pain?

Yes

No

Not available

Date/time of first IV pain med administration:

__________________________________
(leave blank if unknown)

Minutes to first IV pain med dose

__________________________________
(minutes between triage and time of administration
of first analgesic dose)

Date/time of first oral pain med administration, if
administered

__________________________________

Pain Medications Administered (Check All that Apply):
Opioid, short-acting, oral:

Codeine
Codeine with Acetaminophen (Tylenol with Codeine;
Capital with Codeine)
Hydrocodone
Oxycodone
Oxycodone with Acetaminophen (Percocet,Endocet,
Roxicet)
Hydromorphone with Acetaminophen (Vicodin)
Hydromorphone (Dilaudid)
Morphine
Other

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Opioid, short-acting, parenteral:

Codeine
Nalbuphine hydrochloride (Nubain)
Fentanyl
Hydromorphone (Dilaudid)
Morphine
Other

Non-Opioid, oral:

Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Ketamine (Ketanets, Ketaset, Ketalar)
Ketorolac (Toradol)
Other

Non-Opioid, parenteral:

Ketorolac (Toradol)
Ketamine (Ketanets, Ketaset, Ketalar)
Other

Opioid, long-acting:

Oxycodone ER (Oxycontin)
Morphine ER (MSContin)
Methadone (Dolophine, Methadone Intensol),
Methadose)
Fentanyl transdermal (Duragesic)
Other

Other pain medications administered:

__________________________________

What date/ time was the patient's pain re-assessed
after first IV pain medication dose using a
quantitative pain assessment scale (0-10 scale)?

__________________________________

Minutes between pain med administration and pain
reassessment time

__________________________________

Notes
Comments:

__________________________________

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