Attachment H_ Nursing Home Medical Record review Form

DEPARTMENT OF
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333

HACO MRSA Study: Long-term Care Facility (LTCF)
Medical Record Review Form (MRRF)
(This form will be filled out only for residence who are residing
at a LTCF after discharge from the hospitalization of interest)

Study ID:
Section 1: Personal Identifiers – NOT transmitted to CDC, Remove from MRRF and keep for site records

LTCF Medical Record Number:

Phone Number:

Last Name:

First Name:

(

)

LTCF Name:
LTCF Address:

City:

CDC xx.xxx Rev. 1-2011

State:

Zip Code:

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Study ID:

HACO MRSA Study: Long-term Care Facility (LTCF) Medical Record Review Form (MRRF)
(This form will be filled out only for residence who are residing at a LTCF after discharge from the hospitalization of interest)
Section 2: Study Identifiers (Completed by EIP site and transmitted to CDC)
2. Date of Birth:

1. Study ID:

3. Gender:

1A. Date of Discharge
from Hospitalization of
Interest:

/

/

1B. Date of initial HACO
MRSA culture for case or
control’s matched-case:

/

/

Unknown

(MM / DD / YYYY)

5. LTCF ID where data
was abstracted:

4. Date of admission to LTCF
after hospitalization of
interest:

Female
Male

(if a case, please list STATE ID. For a control, please list the matched case’s STATE ID-#)

/

6. Date of data
abstraction :

(MM / DD / YYYY)
(Refer to MDS 3.0 Section A1600)

/

/

(MM / DD / YYYY)

/

/

/

(MM / DD / YYYY)

(MM / DD / YYYY)

7. Person who completed the form:

EIP SO

Facility nurse

Initials of Abstractor:

Section 3: Screening Questions
Case Eligibility:
8A. What is the hospital ID of the acute care facility where resident stayed for 3 or more nights
between discharge from hospitalization of interest and initial HACO MRSA positive culture?

8. Did this LTCF resident stay > 3 calendar days in an
alternate acute care facility between discharge from
hospitalization of interest on
/
/
(MM / DD / YYYY)

and date of initial HACO MRSA culture

(Date:

/

/

)?

8A.i. Is the acute care facility participating in this study?

(MM / DD / YYYY)

Yes (Go to Q.8A)

No (Go to Q.12)

Unknown (STOP
ABSTRACTION
and EXCLUDE
RESIDENT!)

Yes (Go to Q.8B)
No (STOP ABSTRACTION and EXCLUDE RESIDENT!)

8B. Was the resident admitted back to this same LTCF after discharge from
the above acute care facility where he/she stayed for 3 or more nights?

8B.i. If yes, what was the date of LTCF admission?

/

Yes (Go to Q8.B.i)

No
Unknown
If No or Unknown, STOP abstraction here and go back to new HOI
to determine where the resident was discharged.

/

(mm/dd/yyyy) (Go to Q12)

[Please NOTE: you should use this date as the date of admission to LTCF from
hospitalization of interest. A new MRRF will need to be filled out for this resident]

Control Eligibility:
9. Did this resident die between LTCF admission
[Date:
] and date of initial HACO
/
/
(MM / DD / YYYY)

MRSA culture [Date:

/

/

]?

/

days in an acute care facility between
discharge from hospitalization of interest

/

on

(MM / DD / YYYY)

(MM / DD / YYYY)

Yes, Date of death

11. Did this LTCF resident stay > 3 calendar

10. Did the resident have an invasive MRSA
infection within the 12 weeks after being
discharged from the hospitalization of interest
on
?
/
/

/

and date of

(MM / DD / YYYY)

matched-case’s initial HACO MRSA culture

/

(MM / DD / YYYY)
(EXCLUDE THIS RESIDENT FROM STUDY)

/

(Date:

Yes (List sterile site:

/

)?

(MM / DD / YYYY)

AND EXCLUDE THIS RESIDENT AS CONTROL)

Yes (Exclude this resident)

No (Go to Q.10)

No (Go to Q.12)
Unknown (STOP ABSTRACTION and

No (Go to Q.11)

EXCLUDE RESIDENT!)

Complete remaining sections for all residents
Section 4: Demographics
Please fill out according to MDS 3.0 even though this information may be available in the MRRF
Height and Weight should be available under Section K0200 of the MDS 3.0
Race/Ethnicity should be available under Section A1000 of MDS 3.0 Assessment
completed closest to admission.
12. Race
13. Ethnicity:
Asian
15. Height at admission to LTCF:
White/Caucasian
14. Weight at admission to LTCF:
Hispanic
Black/African American

Native Hawaiian/Pacific Islander

Non-Hispanic

American Indian/Alaskan Native

Unknown

Unknown

(circle): lbs

Unknown

in

Unknown

Section 5: LTFC Stay
Information may be found in Sections A2000/2100 of MDS 3.0 completed closest to date of initial HACO MRSA Culture.
16A.i. If yes, Date of Discharge from LTCF:
16. Was this resident discharged from LTCF before
the date of matched-case’s/case’s initial HACO MRSA
/
/
(Go to Q.16A.ii)
culture [Date:
]
/
/
(MM / DD / YYYY)

(MM / DD / YYYY)

Yes (Go to Q.16A.i)

No (Go to Q.17)

16A.ii. Where was the resident discharged to?
Home

Other LTCF

Unknown

Other specify:

Acute Care Hospital

Long Term Acute Care Hospital (LTACH)

Unknown (Go to Q.17)
CDC xx.xxx Rev. 1-2011

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Study ID:
Section 6: Clinical Characteristics
17A. If no or unknown, did this resident have a CVC inserted after admission to LTCF
[Date:
] and date of matched-case’s/ case’s initial HACO MRSA
/
/

17. Did this resident have a central venous catheter (CVC) in place on

/

the date of admission to LTCF [Date:

/

]?

(MM / DD / YYYY)

(MM / DD / YYYY)

/

culture [Date:

/

] or discharge (whichever is the earliest)?

(MM / DD / YYYY)

Yes (Go to Q.17B)

No (Go to Q.17A)

Unknown (Go to Q.17A)

Yes (Go to Q.17B)

17C. Indicate location of CVC insertion:

17B. Indicate CVC type:
Hemodialysis CVC

Femoral (Fem)

Hickman/Broviac

Internal Jugular (IJ)

Non-tunneled
short-term catheter

Subclavian vein (SC)

PICC

Unknown

Port-a-cath

Other specify:

No (Go to Q.18)

17D. Reasons for CVC insertion:
(Check all that apply)
Blood Transfusion

Parenteral nutrition

Chemotherapy

Unknown

Dialysis

Unknown (Go to Q.18)
17E. Was this CVC still in place on date of
matched-case’s/case’s initial HACO MRSA
culture [Date:
] or
/
/
(MM / DD / YYYY)

discharge (whichever is the earliest)?

Other specify:

IV antibiotics
IV Fluids

Yes (Go to Q.18)
No (Go to Q.17E.i)

Unknown

Unknown (Go to Q.18)

Other specify:

17E.i. If no, date of CVC removal?

/

/

(MM / DD / YYYY)

Unable to Determine/Unknown
(Go to Q.17E.ii)

17E.ii. Check the reason(s) for which CVC
was removed? (Check all that apply):
End of intravenous therapies
Exit site infection
Fever
Other specify:
Unknown

17E.vi. If yes, what date was this second CVC inserted?

/

/

(MM / DD / YYYY)

17E.iii. After this CVC was removed, did the resident have another CVC placed
before date of matched-case’s/case’s initial HACO MRSA culture

/

[Date:

/

] or discharge (whichever is the earliest)?

(MM / DD / YYYY)

Yes (Go to Q.17E.i.v.)

No (Go to Q.18)

Unknown (Go to Q.18)

17E.v. How long was the second CVC in place up to date of matched-case’s/case’s initial HACO MRSA

/

culture [Date:

(Go to Q.17E.v.)

/

] or discharge (whichever is the earliest)?

(MM / DD / YYYY)

days or

Unknown (Go to Q.18)

18. Did this resident have any wounds at admission to LTCF [Date:
matched-case’s initial HACO MRSA culture [Date:

/

Unknown

week

/

/

Still with the CVC

] or develop any wound(s) between admission and date of case’s/

(MM / DD / YYYY)

/

] or discharge/transfer from LTCF (whichever is earliest)?

(MM / DD / YYYY)

(Use MDS 3.0 Sections M0210, M1030, and M1040 completed closest to admission AND closest to date of initial HACO MRSA culture or discharge/transfer from LTCF (whichever is earliest).

Yes (Go to Q.18A)

No (Go to Q.19)

Unknown (Go to Q.19)

18A. If Yes, complete the following table using the Key by filling in corresponding # in the table:
Time

Type

Location

Debridement Performed
prior to case’s/matchedcase’s initial HACO MRSA
culture?

Did the wound heal prior to
case’s/matched-case’s initial
HACO MRSA culture?

Key:
Time:

Type:

Location:

Debridement:

Healed:

1-On admission

1-Decubitus/Pressure Ulcer

1-Arm/Hand

8-Sacral/buttock

1-Yes

1-Yes

2-After admission

2-Diabetic Ulcer

2-Belly

9-Shoulder

0-No

0-No

3-Surgical Wound

3-Chest

11-Leg

7-Unknown

7-Unknown

4-Traumatic Wound

4-Forefoot

12-Hip

5-Skin Abscess/Boil

5-Head/neck

10-Other, specify

6-Other, specify

6-Heel

7-Unknown

7-Unknown
CDC xx.xxx Rev. 1-2011

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Study ID:
18B. List the date the resident last received wound care on any wound between admission to LTCF [Date:

/

/

] and date of

(MM / DD / YYYY)

matched-case’s/case’s initial HACO MRSA culture [Date:

/

/

] or discharge (whichever is earliest)? (Please use the resident’s LTCF medical

(MM / DD / YYYY)

record) Date:

/

/

Unknown / not documented

(MM / DD / YYYY)

Section 7: Antimicrobial Exposures
19. Was the resident admitted to LTCF on ANY (PO or IV) antimicrobial therapy?
19A. If yes, check all antimicrobials the resident was admitted with?
Cefoxitin
Amikacin
Daptomycin
Dicloxacillin
Ceftazidime
Amoxicillin
Amox/clav
Ertapenem
Ceftriaxone
Cefuroxim
Gentamicin
Amp/sulb
Azithromycin
Cephalexin
Imipenem
Cefpodoxime
Levofloxacin
Aztreonam
Ciprofloxacin
Cefazolin
Linezolid
Clindamycin
Cefepime
Metronidazole
Meropenem
Clarithromycin
Cefotaxime

Yes (Go to Q.19A)

Moxifloxacin
Nafcillin
Nitrofurantoin
Norfloxacin
Penicillin
Piperacillin/tazo
Rifampin
Tobramycin

No (Go to Q.20)

Unknown (Go to Q.20)

TMP/SMZ
Vancomycin
Other specify:

Tigecyclin

20. Did the resident receive antimicrobial therapy in the 4 weeks prior to date of matched-case’s/case’s initial HACO MRSA culture [Date:
Yes (Go to Q.20A)

No (Go to Q.21)

/

/

]

(MM / DD / YYYY)

Unknown (Go to Q.21)

20A. If yes, please fill out table below:

Antimicrobial Name

Route (PO/IV)

Start date
(mm/dd/yyyy)

Was active by the time
of case’s/matched-case’s
invasive HACO
MRSA culture ?
Yes

If no, end date
(mm/dd/yyyy)

Indication

No

Unknown
Yes

No

Unknown
Yes

No

Unknown
Yes

No

Unknown
Yes

No

Unknown
Yes

No

Unknown
Yes

No

Unknown

CDC xx.xxx Rev. 1-2011

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Study ID:
Section 8: Functional Status
21. What was the resident’s functional status at LTCF admission; as reported in Section G of MDS 3.0 on Admission, ‘self performed’?:
You will use the number as reported in MDS 3.0. The coding is provided here just for your reference
0. Independent
1. Supervision
2. Limited assistance
3. Extensive assistance
4. Total dependence
Bed mobility (Section G0110 A on MDS 3.0):

Transfer (Section G0110 B on MDS 3.0):

Locomotion on unit (Section G0110 E on MDS 3.0):

Dressing (Section G0110 G on MDS 3.0):

Eating (Section G0110 H on MDS 3.0):

Bathing (Section G0120 A on MDS 3.0):

Section 9: Additional Healthcare Exposures
22. Did this resident have any ED visit between
LTCF admission [Date:
] and
/
/
(MM / DD / YYYY)

Use MDS 3.0 Section O0100 Letter J Column “While a
Resident” to answer the following question

matched-case’s/case’s initial HACO MRSA culture
[Date:
] or discharge
/
/

admission [Date:

(whichever is the earliest)?

[Date:

24. Did this resident receive dialysis between LTCF

(MM / DD / YYYY)

date of matched-case’s/case’s initial HACO MRSA
culture [Date:
] or discharge
/
/
(MM / DD / YYYY)

(which ever is the earliest)?
Yes (Go to Q.22A)

23. Did this resident have any surgery performed
in an operating room between LTCF admission
[Date:
] and date of
/
/

(MM / DD / YYYY)

No (Go to Q.23)

Yes (Go to Q.23A)

Unknown (Go to Q.23)

] and date

/

/

] or discharge

(MM / DD / YYYY)

whichever is the earliest)?

23A. If yes, what was the surgical procedure?
22A. If yes, how many ED visits did this resident
have during this time period:

/

of matched-case’s/case’s initial HACO MRSA culture

No (Go to Q.24)

Unknown (Go to Q.24)

/

(MM / DD / YYYY)

Yes (Go to Q.24A)

No (Go to Q.25)

Type:
23A.i. On what date did this occur?
Date:

/

24A. What type of dialysis did this resident receive?
Peritoneal (PD)

/

(MM / DD / YYYY)

Hemodialysis (HD)

Unknown

Use MDS 3.0 Section O0100 Letter E and F Column “While a Resident” to answer the following question.

25. Did this resident receive tracheostomy, ventilator, or respirator care between LTCF admission [Date:
case’s initial HACO MRSA culture [Date:

/

/

(MM / DD / YYYY)

] or discharge (whichever is the earliest)?

/

/

(MM / DD / YYYY)

Yes

] and date of matched-case’s/

No

Section 10: History of MRSA Infection
26. Did this resident have a positive MRSA culture from a non-sterile site between LTCF admission [Date:
case’s initial HACO MRSA culture [Date:
] or discharge (whichever is the earliest)?
/
/

/

/

(MM / DD / YYYY)

] and date of matched-case’s/

(MM / DD / YYYY)

Yes (Go to Q.26A)

No

Unknown

26A. If yes, list the date and site of most recent positive MRSA Culture (please note that this resident is eligible for the sub-study):

/

/

(MM / DD / YYYY)

Culture Site:

Comments:

CDC xx.xxx Rev. 1-2011

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