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______ |
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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_________________________________________________
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
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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 |
______ |
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______ |
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: __ __/__ __/__ __
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 |
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[ ] IV [ ] IM |
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[ ] IV [ ] IM |
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[ ] IV [ ] IM |
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[ ] IV [ ] IM |
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[ ] IV [ ] IM |
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Transfusions during surgery?
Type |
Dose |
Time start |
Time stop |
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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 |
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Grafts |
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Staples/sutures |
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Drains |
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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 |
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[ ] IV [ ] IM |
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[ ] IV [ ] IM |
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[ ] IV [ ] IM |
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[ ] IV [ ] IM |
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Transfusions after surgery?
Type |
Dose |
Date and time start |
Date and time stop |
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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 |
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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:_________________________________
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 ________
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 |
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______ |
___________ |
___________ |
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
Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Nguyen, Duc (CDC/OID/NCEZID) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |