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Records Abstraction Information
ICR 201507-0920-005 · OMB 0920-1011 · Object 57443101.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Records Abstraction Information |
| Author | Nguyen, Duc (CDC/OID/NCEZID) (CTR) |
| Last Modified By | Writer |
| File Modified | 2015-07-26 |
| File Created | 2026-08-31 |
| Conversion State | complete |
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APPENDIX 2 – MEDICAL CHART ABSTRACTION FORM – PA NTM INFECTIONS
Abstractor: Date of abstraction: ____ / ____ / ____
Case ID:_____________
This patient is a: 1 [ ] Case 2 [ ] Control
Pathogen
Infection site
Specimen
Date specimen obtained
Test performed
[ ] M. abscessus
[ ] M. chelonae
[ ] M. fortuitum
[ ] M. something
[ ] BSI
[ ] SSI
[ ] Respiratory
[ ] CAUTI
[ ] Skin/soft tissues
[ ] Other_______
[ ] Blood
[ ] Tissue/Biopsy
[ ] BAL/BW
[ ] Urine
[ ] Swab
[ ] Other______
_ _/_ _/_ _
[ ] Culture
[ ] PCR
[ ] Histopath
[ ] Other______
A. Patient information
Sex: 1 [ ] Male 2 [ ] Female 9 [ ] N/A
Year of birth/Age:__________
Race/Ethnicity:
1 [ ] White 2 [ ] Afr Am 3 [ ] Hispanic 4 [ ] Asian/PI 5 [ ] AI/AN
7 [ ] Other, specify:_______ 9 [ ] Unknown
Hospital/clinic admission date: __ __/__ __/__ __ (mm/dd/yy)
Admission diagnosis______________________________________________
Onset date: __ __/__ __/__ __ (mm/dd/yy)
Chief complaints_________________________________________________
B. History and Physical
Secondary Diagnoses (patient medical history):
[ ] CAD [ ] Rheumatoid Arthritis [ ] Solid tumor (non-metastatic) [ ] CHF [ ] Connective tissue disease [ ] Metastatic solid tumor
[ ] PVD [ ] Mild liver disease [ ] Lymphoma
[ ] Dementia [ ] Moderate-to-severe liver disease [ ] PUD
[ ] Chronic pulmonary disease [ ] Diabetes w/o complications [ ] AIDS (CD4<200 or OI)
[ ] Hemiplegia [ ] Diabetes w/end organ disease [ ] Inflammatory bowel disease
[ ] Moderate to severe renal disease (Cr>=3.0, h/o uremia, transplant) [ ] Ulcer disease
[ ] Leukemia [ ] Obesity [ ] Hypertension
Other:__________________________________________________________________
Current alcohol use 1 [ ] Yes, amount (drinks/week): _________ 2 [ ] No 9 [ ] Unknown
Smoking status (at admission) 1 [ ] Yes, amount (pack-years):___2 [ ] No 9 [ ] Unknown
Any prior history of smoking? 1 [ ]Yes, pack-year history ___ [ ] No 9 [ ] Unknown
Other history related to this hospitalization
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Any medications used prior to admission
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
C. Hospital course
Patient location/procedures/movements in the hospital … days before first positive culture:
(procedures may include central line insertion/care, catheter insertion, ultrasound, endoscopy…)
Building
Tower
Unit
Room
Dates
Procedure
Staff encounter
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
D. If BSI, consider the following
Central line is present: [ ] Yes [ ] No
If Yes, then
Date inserted
Type
Active during 1 week before culture
__ __/__ __/__ __
[ ] CVC
[ ] PICC
[ ] Port
[ ] Swan-Ganz
[ ] Other___________
[ ] Yes [ ] No
__ __/__ __/__ __
[ ] CVC
[ ] PICC
[ ] Port
[ ] Swan-Ganz
[ ] Other___________
[ ] Yes [ ] No
Central line access (within 1 week of positive culture)
Date accessed
Staff
Procedure
Saline flush
Medications administered
_ _/_ _/_ _
___________
[ ] Flush
[ ] Dressing change
[ ] Med administration
[ ] Other____
[ ] Yes [ ] No
__________ (note if something is multi-dose vial)
_ _/_ _/_ _
___________
[ ] Flush
[ ] Dressing change
[ ] Med administration
[ ] Other____
[ ] Yes [ ] No
__________ (note if something is multi-dose vial)
Other medications administered parenterally (not via central line)
Date
Staff
Route/site
Medications administered
_ _/_ _/_ _
___________
[ ] IV_____________
[ ] IM_____________
[ ] SC_____________
__________ (note if something is multi-dose vial)
_ _/_ _/_ _
___________
[ ] IV_____________
[ ] IM_____________
[ ] SC_____________
__________ (note if something is multi-dose vial)
Did patient have a shower/bath during the week before positive culture [ ] Yes [ ] No
Date shower 1: __ __/__ __/__ __
Date shower 2: __ __/__ __/__ __
Date shower 3: __ __/__ __/__ __
E. If SSI, consider the following
Weight__________lbs/kg Height______________in/cm on admission date
Highest glucose in 48 hours prior to surgery:_________Date: __ __/__ __/__ __ Time: __:__
HgbA1c value within 3 months of surgery (take most recent value):______Date: __ __/__ __/__ __
Pre-op albumin level:_________ Date: __ __/__ __/__ __ Time: __:__
ASA Score: _________ NYHA Score:__________ Preop EF:_______________
Date of surgery __ __/__ __/__ __
Antibiotics used
Pre-op Abx use [ ] Yes [ ] No
Name
Route
Dose
Date
Time start
________
[ ] IV [ ] IM
________
_ _/_ _/_ _
__:__
________
[ ] IV [ ] IM
________
_ _/_ _/_ _
__:__
Intra-op Abx use [ ] Yes [ ] No
Name
Route
Dose
Date
Time start
________
[ ] IV [ ] IM
________
_ _/_ _/_ _
__:__
________
[ ] IV [ ] IM
________
_ _/_ _/_ _
__:__
Intra-op Abx use [ ] Yes [ ] No
Name
Route
Dose
Date
Time start
________
[ ] IV [ ] IM
________
_ _/_ _/_ _
__:__
________
[ ] IV [ ] IM
________
_ _/_ _/_ _
__:__
Antiseptic showering □ Yes, type and date given: ____________________ □ No
Pre-op hair removal: □ none □ razor □ clipper □ Other ______________________
Pre-op prep: □ CHG □ Betadine □ Other ______________________
Any special skin preparation: ______________________________________________________
______________________________________________________________________________
Surgical procedures (briefly, e.g., CABGx2, LIMA harvest…):
________________________________________________________________________
If this is a CABG, what is the harvest site_____________________________
Surgery start time:___________
Surgery stop time:___________
OR Room #: ______
Surgeon ________________________ Anesthesiologist _________________________
RFNA____________________________ CRNA _________________________
RFNA____________________________ Perfusionist _____________________________
Scrub Nurse(s)___________________ Personal Scrub ___________________________
Circulator 1 _______________________ Circulator 2_________________________
Other (name/title)__________________ Other (name/title)_________________________
Did patient have Cardiopulmonary Bypass (CBP)? 1 [ ] Yes 2 [ ] No 9 [ ] Unknown
Intraoperative US (e.g., TEE) performed: 1 [ ] Yes 2 [ ] No 9 [ ] Unknown
If yes, by whom? _________________
Cardioplegia or similar intervention 1 [ ] Yes 2 [ ] No 9 [ ] Unknown
If yes, what was used for the procedure____________________________________
Other IV drugs during surgery?
Type
Dose
Route
Time start
Time stop
[ ] IV [ ] IM
[ ] IV [ ] IM
[ ] IV [ ] IM
[ ] IV [ ] IM
[ ] IV [ ] IM
Transfusions during surgery?
Type
Dose
Time start
Time stop
Highest glucose during procedure:____________ Time: __:__
List all the devices or equipment that were inserted into patient’s body (valve, grafts, drains, staple/suture, wound dressing…)
Instrument type
Name
Catalog #
Serial #
Check if left in place
Date removed
Grafts
Staples/sutures
Drains
Other intra-operative findings (including cooling methods, drugs in/on chest, dressing, ointment…):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Post operation
ICU recovery room _______________ Admission date: __ __ /__ __/__ __ Time:__ __:__ __
Did patient have warmers (forced air warming blanket, etc)…1 [ ] Yes 2 [ ] No 9 [ ] Unknown
Medications (suppressors, immunosuppressant) after surgery?
Type
Dose
Route
Date and time start
Date and time stop
[ ] IV [ ] IM
[ ] IV [ ] IM
[ ] IV [ ] IM
[ ] IV [ ] IM
Transfusions after surgery?
Type
Dose
Date and time start
Date and time stop
Highest glucose within 24 hours post operation:__________ Date: __ __/__ __/__ __ Time: __:__
Wound care after surgery:
Dressing change (one change per line, regardless of products used) or wound cleansing
Dressing/cleansing product
Date change
Time change
Staff name
Note
Date of dressing removal __ __ /__ __/__ __ [ ] N/A
Date of staple/suture removal __ __ /__ __/__ __ [ ] N/A
Date of drain removal __ __ /__ __/__ __ [ ] N/A
Other interventions in or around the wound (date) _______________________________________
Did patient have a shower/bath during hospitalization after surgery [ ] Yes [ ] No
Date shower 1: __ __/__ __/__ __
Date shower 2: __ __/__ __/__ __
Date shower 3: __ __/__ __/__ __
If SSI is related to endoscopy/laparoscopy
Date
Type and site of endoscopy
Interpretation
Meds used during bronchoscopy
Location (Bedside, Radiology) and staff
__ __ /__ __/__ __
___________
________________
_______________
________________
__ __ /__ __/__ __
___________
________________
_______________
_______________
__ __ /__ __/__ __
___________
________________
_______________
_______________
Abx used before admission for SSI 1 [ ] Yes 2 [ ] No 9 [ ] Unknown
If Yes, start date__ __/__ __/__ __ and drug name______________________
SSI symptoms:
Fever 1 [ ] Yes 2 [ ] No 9 [ ] Unknown
Wound findings: 1 [ ] Superficial 2 [ ] Deep 3 [ ] Organ space
Site of the wound _____________ 9 [ ] Unknown
Drainage 1 [ ] Yes 2 [ ] No
Swelling 1 [ ] Yes 2 [ ] No
Erythema 1 [ ] Yes 2 [ ] No
Pain 1 [ ] Yes 2 [ ] No
Other symptoms:_________________________________________________________________
Wound Classification: □ Clean □ Clean-Contaminated □ Contaminated □ Dirty
Wound treatment:
Surgical Debridement 1 [ ] Yes 2 [ ] No Date __ __ /__ __/__ __
Wound Vac 1 [ ] Yes 2 [ ] No Date __ __ /__ __/__ __
Flap 1 [ ] Yes 2 [ ] No Date __ __ /__ __/__ __
Antibiotics 1 [ ] Yes 2 [ ] No start date __ __ /__ __/__ __
Specify agent/dose/route:________________________________________
Other medications 1 [ ] Yes 2 [ ] No Date __ __ /__ __/__ __ Specify:_________________________________
F. If respiratory infections, consider the following
List RTs who had contact with the patient before first positive culture date:
Name
Date
_______________________
__ __ /__ __/__ __
_______________________
__ __ /__ __/__ __
_______________________
__ __ /__ __/__ __
_______________________
__ __ /__ __/__ __
Respiratory Meds received before first positive culture? □ YES □NO
Include O2, NO or other inhaled agents (e.g. albuterol, anesthesia meds, inhaled antibiotics, inhaled asthma meds) in this section
Name (use generic name)
Type/Route (eg MDI, Neb, nasal canula)
Date administered
_____________
_______________
__ __ /__ __/__ __
_____________
_______________
__ __ /__ __/__ __
_____________
_______________
__ __ /__ __/__ __
_____________
_______________
__ __ /__ __/__ __
Antibiotics received before first positive culture? □YES □NO
Name
Dose
Route
Dates administered
_____________
_____________
[ ] IV [ ] IM [ ] PO
__ __ /__ __/__ __
_____________
_____________
[ ] IV [ ] IM [ ] PO
__ __ /__ __/__ __
_____________
_____________
[ ] IV [ ] IM [ ] PO
__ __ /__ __/__ __
_____________
_____________
[ ] IV [ ] IM [ ] PO
__ __ /__ __/__ __
Routine care items/treatments/nutrition received before first positive culture
Mouthwash: Yes No If yes, brand__________________________
Lip balm: Yes No If yes, brand__________________________
Nasal spray: Yea No If yes, brand__________________________
Deodorant: Yes No If yes, brand__________________________
Chlorhexidine: Yes No If yes, brand__________________________
Antiseptics: Yes No If yes, name__________________________
Tube feeds: Yes No If yes, tube type_______________________
Feed fluid name_______________________
Shaving gel: Yes No If yes, brand__________________________
Other products:
Name_______________________________ Brand____________________________
Name_______________________________ Brand____________________________
Name_______________________________ Brand____________________________
Name_______________________________ Brand____________________________
Were steroids administered before first positive culture? □Yes □No
If yes, dose __________________ dates administered__/__/____-__/__/____
__/__/____-__/__/____
Was suctioning done: □Yes □No
If yes, dates __/__/____-__/__/____
How many times did the patient receive suctioning within the exposure window: _______________
Any solutions/fluid used during the procedure_____________________
Was bronchoscopy done: □Yes □ No
If yes fill the table below:
Date
Interpretation
Meds used during bronchoscopy
Location (Bedside, Radiology) and staff
Specimen obtained
__ __ /__ __/__ __
__________________
_______________
________________
1 [ ] Yes 2 [ ] No
__ __ /__ __/__ __
__________________
_______________
_______________
1 [ ] Yes 2 [ ] No
__ __ /__ __/__ __
__________________
_______________
_______________
1 [ ] Yes 2 [ ] No
Ventilation
Did patient require mechanical ventilation before first positive culture date? □YES □ NO
Vent brand/serial number________________________________
If yes, date intubated __/__/____
Location where intubated________________________
Date extubated __/__/____
Did the patient have or receive a tracheostomy during the exposure window? □YES □NO
If yes, date procedure performed __/__/____
Location where tracheotomy done________________________
Did patient require CPAP? □YES □NO
If yes, # of days on CPAP before first positive culture_______
Did patient require BIPAP? □YES □ NO
If yes, # of days on BIPAP before first positive culture ________
G. If CAUTI, consider
Is patient incontinence 1 [ ] Yes 2 [ ] No
Catheter information
Date inserted
Date withdrawn
Type
__ __/__ __/__ __
__ __/__ __/__ __
[ ] Urinary catheter
[ ] Suprapubic catheter
[ ] Temporary relief
[ ] Other___________
__ __/__ __/__ __
__ __/__ __/__ __
[ ] Urinary catheter
[ ] Suprapubic catheter
[ ] Temporary relief
[ ] Other___________
If catheter was accessed or maneuvered, provide information
Date accessed
Staff
Procedure
Bag drain
_ _/_ _/_ _
___________
___________
[ ] Yes [ ] No
_ _/_ _/_ _
___________
___________
[ ] Yes [ ] No
H. Patient symptoms and other laboratory data
[ ] Fever
[ ] Chills
[ ] Abdominal pain
[ ] Cough
[ ] Hemoptysis
[ ] Dyspnea
[ ] Respiratory failure
[ ] Shock
CBC and chemistry
Date specimen obtained
WBC
ALT
AST
…
_ _/_ _/_ _
___________
___________
___________
___________
_ _/_ _/_ _
___________
___________
___________
___________
Urinalysis
Date specimen obtained
WBC
RBC
…
…
_ _/_ _/_ _
___________
___________
___________
___________
_ _/_ _/_ _
___________
___________
___________
___________
Other culture
Date specimen obtained
Source of specimen
Test
Result
…
_ _/_ _/_ _
___________
[ ] Culture
[ ] PCR
[ ] Histopath
[ ] Other______
___________
___________
_ _/_ _/_ _
___________
[ ] Culture
[ ] PCR
[ ] Histopath
[ ] Other______
___________
___________
I. Patient treatment and outcome
Antibiotic received
Name
Route
Dose
Date start
Date stop
______________
[ ] IV [ ] IM [ ] PO
_________
_ _/_ _/_ _
_ _/_ _/_ _
______________
[ ] IV [ ] IM [ ] PO
_________
_ _/_ _/_ _
_ _/_ _/_ _
Patient outcome of this hospitalization?
1 [ ] Recover and discharged 2 [ ] Died 3 [ ] Still in hospital
4 [ ] Other____________________ 9 [ ] Unknown