Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Chart Abstraction Form
Patient Medical Record Number: _____________________________________
Patient Name : _____________________________________
Unique CDC Patient ID:____________________________________________
Unique CDC Patient ID: ________________________
Session Number : ________________________
□ Case □ Control
Chart abstractor: □ WCE □ DN □ ?? □ ?? □ ?? □ Other:______
Reviewed: □ Outpatient record □ Micro Results □ Reprocessing records
Demographics (779)
Age: _____________
Sex: □M □F
Ethnicity: □ Hispanic or Latino
□ Non-Hispanic
□ Unknown
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
Cause of ESRD (797): □Diabetes □ Hypertension
□Glomerulonephritis □Cystic Kidney Disease
□Urologic Disease
□Other1 (describe): ________________________
□Other2 (describe): ________________________
□Unknown cause □ Not documented
Medical History & Problem List
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
Access type (and location if catheter) (7478):
□ Fistula □ Graft
□ Catheter
Location: (IJ, femoral, subclavian) ______________________________
If catheter: □ cuffed □ uncuffed
□ Other (specify) ______________________________
Date of access insertion: ___________________
Dialysis schedule (68): □ M/W/F □ Tu/Th/S
Usual shift (68): _______________
DIALYSIS SESSION JUST PRIOR TO POSTIVE BLOOD CULTURE DRAWN (CASES) OR SELECTED SESSION (CONTROLS)
Date of session: ________________________________
Shift of day (68): ___________________________________
Any symptoms pre-dialysis? (84748): □ Y □ N
If yes, list: ________________________________
Start time of dialysis (68):____________
End time of dialysis (68):_____________
Dialyzer type/Brand (74754) _____________
Header? □ Y □ N
Acid Bath (74777): _____________________________
Was dialyzer preprocessed? □ Y □ N
Explain: ______________________________
Was dialyzer reprocessed (74754)? □ Y □ N
If Yes, last use number: ________ today’s use: ____________
Reprocessing date / time: ________________
Person who reprocessed: ________________
Renatron machine number: _______
Date / time of last use of that dialyzer: ________________
Storage/Refrigeration Time: ______________
On-site reprocessing? □ Y □ N
If NO, list the location: _______________________
If NO, when was it shipped out: ________________
Is there documentation of the presence of germicide check (74754)?
□ Y □ N □ N/A
Dialysis machine brand name (74759): ______________________
Dialysis machine number (74756): ______________________
Dialysis station (68): ______________________
Unit (68): _________________
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: ________
Describe post-dialysis access care? (Dressing type or ointment used, etc.)
New dressing applied: □ Y □ N □ Unknown
If yes, dressing type: ________________________________________
Antimicrobial ointment applied to exit site: □ Y □ N □ Unknown
If yes, describe: ________________________________
Any notable/unusual events that occurred during the dialysis session?
□ Y □ N □ Unknown
If yes, describe: ________________________________
Symptoms (84749):
□ Fever, Tmax: _______ □ Chills □ Low blood pressure
□ Lethargy
□ Other: ___________________
Did symptom onset occur during dialysis (8478)? □ Y □ N
If Yes, Was dialysis discontinued prematurely/SHTX? □ Y □ N
For cases:
Date symptom onset: ___________________
Time of symptom onset (in relation to dialysis session): ___________________
Culture date: _______________________________________
Number of sets: ____________
Drawn from: □ Dialysis tubing □ Catheter □ Peripheral stick
Culture results:
□ B. cepacia □ P. aeruginosa □ R. pickettii
□ S. maltophilia
□ Other organism (list): _______________________________
Treatment: _________________________________________
Antibiotics start date and time: _________________________________________
Were antibiotics given before cultures drawn? □ Y □ N
ER transport: □ EMS □ Private vehicle □ N/A
Admitted? □ Y □ N
If yes, admission date: ________________
Discharge date:___________________
Name of hospital: ________________
If yes ICU? □ Y □ N
Developed sepsis / cardiovascular collapse requiring pressors: □ Y □ N
Deceased: □ Y □
If deceased, date of death: ________________
Other outcomes:
□ Catheter infected/removed □ graft infected/removed
□ Others: _________________________________________
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)
File Type | application/msword |
File Title | Dialysis Record |
Author | EIS08 |
Last Modified By | Patel, Priti (CDC/OID/NCEZID) |
File Modified | 2014-09-12 |
File Created | 2014-09-11 |