Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Undetermined
source for Salmonella
Infantis infections among detention center inmates — South
Carolina, 2016 Chart
abstraction form to be used by federal employees
MEDICAL RECORD ABSTRACTION FORM
CDC ID: Date: // Data collector initials: _____
Patient’s Name:
Unit:
DOB: //
When was the first documented episode of diarrhea: //
Admission date: //
Discharge date: //
MEDICAL RECORD ABSTRACTION FORM
CDC ID: Date: // Data collector initials: _____
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Part 1. Demographic Information |
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1. Gender: M F Unknown |
American Indian or Alaska Native Asian Black or African American White Native Hawaiian/other Pacific Islander Unknown Other race |
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Hispanic or Latino Not Hispanic or Latino Unknown |
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_________ Hours Days Did not go to medical unit Unknown |
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MEDICAL RECORD ABSTRACTION FORM
CDC ID: Date: // Data collector initials: _____
No antimicrobial medication was given Yes antimicrobial medication was given (please list them below)
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CDC ID: Date: // Data collector initials: _____
Part 2. Medical unit Information |
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MEDICAL RECORD ABSTRACTION FORM
CDC ID: Date: // Data collector initials: _____
Probiotics (specify: ________________________________) Analgesic/antipyretic medication (specify: ___________________) Antidiarrheal medication (specify: __________________________) Antiemetic medication (specify: ____________________________) Antimicrobial medication (specify: __________________________) Oral fluids for rehydration (specify: _________________________) Intravenous fluids for rehydration (specify: ___________________) Other: __________________________________ Other: __________________________________
No antimicrobial medication was ever given
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MEDICAL RECORD ABSTRACTION FORM
CDC ID: Date: // Data collector initials: _____
Part 3. Laboratory testing – Positive Culture Data |
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If “Yes,” complete the table below.
Positive Cultures
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MEDICAL RECORD ABSTRACTION FORM CDC ID: Date: // Data collector initials: _____
Complete the AST table below by filling in the culture no. from the positive culture table, checking the appropriate pathogen, and circling the corresponding AST results.
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Culture-Independent Diagnostic Tests:
Test |
Results & Notes |
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END OF ABSTRACTION
Public reporting burden of this collection of information is estimated to average 0 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/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Shelley Magill |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |