Form 28 Attachment 12 Form 10a Chart Review -Inpatient Hospitali

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OMB Number 0925-XXXX

Exp. Date: XX/XX/XXX

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CEIRS Human Influenza Surveillance Study Form 10A: Chart Review – Inpatient Hospitalization

Review the subject’s medical record for the day of enrollment and the subsequent 21 days for inpatient hospitalizations.

How many times was the subject hospitalized and admitted in the past 21 days? times

If none, skip to Form 11: 3-week Follow-up Other Doctors Visits

Inpatient Hospitalization Visit 1

Date: / / (mm/dd/yyyy)

Inpatient Hospitalization Visit 2

Date: / / (mm/dd/yyyy)

Inpatient Hospitalization Visit 3

Date: / / (mm/dd/yyyy)

Inpatient Hospitalization Visit 4

Date: / / (mm/dd/yyyy)

Inpatient Hospitalization Visit 5

Date: / / (mm/dd/yyyy)

Inpatient Hospitalization Visit 6

Date: / / (mm/dd/yyyy)

For each inpatient hospitalization, complete a separate Inpatient Hospitalization Chart Review

Form.

Page 1 of 4 Form 10A: Hospital chart review Version 2.0 01/05/2015

Inpatient Hospitalization Chart Review Form

Instructions: For each inpatient hospitalization, complete an Inpatient Hospitalization Chart Review Form. Begin with visit one and number sequentially. Do not including any information from ED visits.

Inpatient Hospitalization #

1. Date inpatient stay began: __/ / (mm/dd/yyyy)

2. Date inpatient stay ended: __/ / (mm/dd/yyyy)

3. Did the subject receive supplemental oxygen in the hospital?

3a. If yes, how much? _L/min 3b. What was the route?

• No Yes Unknown

• Nasal cannula Facemask/non-rebreather BiPAP or CPAP Intubated

4. Was subject located in an intensive care unit? No Yes  Unknown If yes,

4a. Date ICU stay began: / / (mm/dd/yyyy) 4b. Total number of days spent in ICU: _

5. Did Subject die in the hospital? No Yes  Unknown 5a. If yes, Date of Death: / / (mm/dd/yyyy)

6. Did the subject receive antibiotics in the hospital? No Yes  Unknown 6a. If yes, how many antibiotics were received? antibiotics

6b. For each antibiotic received, specify the antibiotic name, the date the antibiotic was started, the number of days it was taken for, and the condition for which it was prescribed.

6i. Antibiotic 1

Antibiotic 1 Name:

Antibiotic 1 start date: __/ / (mm/dd/yyyy) Antibiotic 1 number of days taken: days Antibiotic 1 indication:

6ii. Antibiotic 2

Antibiotic 2 Name:

Antibiotic 2 start date: __/ / (mm/dd/yyyy) Antibiotic 2 number of days taken: days Antibiotic 2 indication:

6iii. Antibiotic 3

Antibiotic 3 Name:

Antibiotic 3 start date: __/ / (mm/dd/yyyy) Antibiotic 3 number of days taken: days Antibiotic 3 indication:

6iv. Antibiotic 4

Antibiotic 4 Name:

Antibiotic 4 start date: __/ / (mm/dd/yyyy) Antibiotic 4 number of days taken: days Antibiotic 4 indication:

7. Did subject receive influenza testing in the hospital? No Yes  Unknown 7a. If yes, how many? influenza tests

7b. For each influenza test, specify the following: 7i. Test 1

7ii. Test 2

Test 1 Name:

Test 1 Type: PCR DFA Culture Antigen Other: Test 1 Result: Negative Positive Other

Test 1 Collection Date: / / (mm/dd/yyyy) Test 1 Collection time (24-hour clock): : (hh:mm) Test 1 Result Date: / / (mm/dd/yyyy) Test 1 Result Time (24-hour clock): : (hh:mm)

Was influenza typing was performed? No Yes  Unknown If yes, please list influenza type:

Test 2 Name:

Test 2 Type: PCR DFA Culture Antigen Other: Test 2 Result: Negative Positive Other

Test 2 Collection Date: / / (mm/dd/yyyy) Test 2 Collection time (24-hour clock): : (hh:mm) Test 2 Result Date: / / (mm/dd/yyyy) Test 2 Result Time (24-hour clock): : (hh:mm)

Was influenza typing was performed? No Yes  Unknown If yes, please list influenza type:

7iii. Test 3

7iv. Test 4

Test 3 Name:

Test 3 Type: PCR DFA Culture Antigen Other: Test 3 Result: Negative Positive Other

Test 3 Collection Date: / / (mm/dd/yyyy) Test 3 Collection time (24-hour clock): : (hh:mm) Test 3 Result Date: / / (mm/dd/yyyy) Test 3 Result Time (24-hour clock): : (hh:mm)

Was influenza typing was performed? No Yes  Unknown If yes, please list influenza type:

Test 4 Name:

Test 4 Type: PCR DFA Culture Antigen Other: Test 4 Result: Negative Positive Other

Test 4 Collection Date: / / (mm/dd/yyyy) Test 4 Collection time (24-hour clock): : (hh:mm) Test 4 Result Date: / / (mm/dd/yyyy) Test 4 Result Time (24-hour clock): : (hh:mm)

Was influenza typing was performed? No Yes  Unknown If yes, please list influenza type:

Visit of

8. Did subject receive influenza antiviral in the hospital? No Yes  Unknown 8a. If yes, how many antivirals were received? _ influenza antivirals

8b. For each influenza antivirals received, specify the antiviral name, route of administration, and date the influenza antiviral was given.

(Key: PO = by mouth; IN = intranasal; IV = intravenous)

8i. Influenza antiviral 1

Influenza Antiviral 1 Name: _ Influenza Antiviral 1 Route: PO IN  IV

Influenza Antiviral 1 Date administered: __/ / (mm/dd/yyyy) Influenza Antiviral 1 Time administered (24-hour clock): : (hh:mm)

8ii. Influenza antiviral 2

Influenza Antiviral 2 Name: _ Influenza Antiviral 2 Route: PO IN  IV

Influenza Antiviral 2 Date administered: __/ / (mm/dd/yyyy) Influenza Antiviral 2 Time administered (24-hour clock): : (hh:mm)

9.	Did the subject have a final diagnosis of
	9a. Influenza?	No	Yes	Unknown
	9b. Viral Syndrome or Infection?	No	Yes	Unknown
	9c. Pneumonia?	No	Yes	Unknown
	9d. Myocardial Infarction?	No	Yes	Unknown
	9e. Stroke?	No	Yes	Unknown

10. How many final inpatient hospitalization diagnoses did the subject have?

1 2 3 more than three List the ICD-9 codes for up to the first few final inpatient hospitalization diagnoses, up to the first three: (Do not use any E or V codes)

10a. Final Inpatient Diagnosis Code 1: 10b. Final Inpatient Diagnosis Code 2: 10c. Final Inpatient Diagnosis Code 3: