Chart Abstraction

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Chart Abstraction Form

Patient Medical Record Number: _____________________________________

Patient Name : _____________________________________

Unique CDC Patient ID:____________________________________________

1. Unique CDC Patient ID: ________________________

1. Session Number : ________________________

2. □ Case □ Control

1. Chart abstractor: □ WCE □ DN □ ?? □ ?? □ ?? □ Other:______

3. Reviewed: □ Outpatient record □ Micro Results □ Reprocessing records

Demographics (779)

4. Age: _____________

5. Sex: □M □F

6. Ethnicity: □ Hispanic or Latino

□ Non-Hispanic

□ Unknown

7. Race (Select all that apply):

□ American Indian/Alaska Native

□ Asian □ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White

□ Unknown

General Dialysis History

8. Cause of ESRD (797): □Diabetes □ Hypertension

□Glomerulonephritis □Cystic Kidney Disease

□Urologic Disease

□Other1 (describe): ________________________

□Other2 (describe): ________________________

□Unknown cause □ Not documented

Medical History & Problem List

9. Comorbid Conditions (7914):

□ Diabetes, DM □ Hypertension, HTN □ HIV / AIDS

□ Coronary artery disease, CAD, CABG □Hepatitis C, HCV

□ Peripheral vascular disease, PVD or PAD □ Anemia

□ Cerebrovascular disease, TIA, stroke □ Malnutrition, wasting

□ Cirrhosis, End-stage liver disease

10. Access type (and location if catheter) (7478):

□ Fistula □ Graft

□ Catheter

Location: (IJ, femoral, subclavian) ______________________________

If catheter: □ cuffed □ uncuffed

□ Other (specify) ______________________________

Date of access insertion: ___________________

11. Dialysis schedule (68): □ M/W/F □ Tu/Th/S

12. Usual shift (68): _______________

DIALYSIS SESSION JUST PRIOR TO POSTIVE BLOOD CULTURE DRAWN (CASES) OR SELECTED SESSION (CONTROLS)

13. Date of session: ________________________________

14. Shift of day (68): ___________________________________

15. Any symptoms pre-dialysis? (84748): □ Y □ N

1. If yes, list: ________________________________

16. Start time of dialysis (68):____________

17. End time of dialysis (68):_____________

18. Dialyzer type/Brand (74754) _____________

19. Header? □ Y □ N

20. Acid Bath (74777): _____________________________

21. Was dialyzer preprocessed? □ Y □ N

    1. Explain: ______________________________

22. Was dialyzer reprocessed (74754)? □ Y □ N

1. If Yes, last use number: ________ today’s use: ____________

2. Reprocessing date / time: ________________

3. Person who reprocessed: ________________

4. Renatron machine number: _______

5. Date / time of last use of that dialyzer: ________________

6. Storage/Refrigeration Time: ______________

7. On-site reprocessing? □ Y □ N

   1. If NO, list the location: _______________________

2. If NO, when was it shipped out: ________________

23. Is there documentation of the presence of germicide check (74754)?

□ Y □ N □ N/A

24. Dialysis machine brand name (74759): ______________________

25. Dialysis machine number (74756): ______________________

26. Dialysis station (68): ______________________

27. Unit (68): _________________

28. Parenteral Medications/infusates given during dialysis (name/dose/time) (74741):

□ Epogen: Dose ___________________ Given by: ________

□ Aranesp: Dose ___________________ Given by: ________

□ Zemplar: Dose ___________________ Given by: ________

□ Ferrlecit: Dose _____________________ Given by: ________

□ Herprin: Dose _____________________ Given by: ________

□ Saline Flush : Quantity _______________ Given by: ________

□ Calcium: Dose _____________________ Given by: ________

□ Other (list): Dose & Time _____________ Given by: ________

□ Other (list): Dose & Time _____________ Given by: ________

29. Describe post-dialysis access care? (Dressing type or ointment used, etc.)

1. New dressing applied: □ Y □ N □ Unknown

2. If yes, dressing type: ________________________________________

3. Antimicrobial ointment applied to exit site: □ Y □ N □ Unknown

4. If yes, describe: ________________________________

5. Any notable/unusual events that occurred during the dialysis session?

□ Y □ N □ Unknown

If yes, describe: ________________________________

30. Symptoms (84749):

□ Fever, Tmax: _______ □ Chills □ Low blood pressure

□ Lethargy

□ Other: ___________________

31. Did symptom onset occur during dialysis (8478)? □ Y □ N

    1. If Yes, Was dialysis discontinued prematurely/SHTX? □ Y □ N

For cases:

1. Date symptom onset: ___________________

2. Time of symptom onset (in relation to dialysis session): ___________________

3. Culture date: _______________________________________

1. Number of sets: ____________

2. Drawn from: □ Dialysis tubing □ Catheter □ Peripheral stick

3. Culture results:

□ B. cepacia □ P. aeruginosa □ R. pickettii

□ S. maltophilia

□ Other organism (list): _______________________________

4. Treatment: _________________________________________

5. Antibiotics start date and time: _________________________________________

6. Were antibiotics given before cultures drawn? □ Y □ N

7. ER transport: □ EMS □ Private vehicle □ N/A

8. Admitted? □ Y □ N

1. If yes, admission date: ________________

2. Discharge date:___________________

3. Name of hospital: ________________

4. If yes ICU? □ Y □ N

9. Developed sepsis / cardiovascular collapse requiring pressors: □ Y □ N

10. Deceased: □ Y □

1. If deceased, date of death: ________________

11. Other outcomes:

□ Catheter infected/removed □ graft infected/removed

□ Others: _________________________________________

12. Other sequelae describe: _______________________________

Public reporting burden of this collection of information is estimated to average 12 minutes per response, 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)