Appx 6 Medical Chart Abstraction Form SAMPLE

Appx 6 MedChartAbstrct Form_SAMPLE_Clean.docx

Assessment of Chemical Exposures (ACE) Investigations - FY2016 Q2 Burden Report

Appx 6 Medical Chart Abstraction Form SAMPLE

OMB: 0923-0051

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Appendix 6: Medical Chart Abstraction Form

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Form Approved

OMB No. 0923-XXXX

Exp. Date XX/XX/20XX

Medical Chart Abstraction Form

Reviewer Name: ________________________ Date of Review: ___ / ___ / ____ Data entered: ___ / ___ / ____

Facility: ___________________________________________ ID: _________

Patient Name: ___________________________________________

Address: Street: ___________________________ City: ___________________ State: _____ Zip: _____________ Telephone (Home) ______________(Cell) ______________(Work) ______________(Other) ______________

Patient Demographics

DOB: ____ / ____ / _______ Sex: □ Male □ Female □ N/A Ethnicity: □ Hispanic □ Not Hispanic

MM DD YYYY

Insurance: Race: (check all that apply)

□ Private □ Medicare/Medicaid/Government program □ American Indian/ Alaskan Native □ Asian □ Black

□ None □ N/A □ Other: ___________________ □ Native Hawaiian/ Pacific Islander □ White


Visit Information

Date of Visit: ____ / ____ / ______ Time of arrival: ____:____ □ am □ pm

MM DD YYYY

Chief Complaint: ___________________________________________________________________________________

Mode of arrival: Was the patient admitted? □ Y □ N

□ Helicopter If yes,

□ Ambulance □ Admitted to monitored ward or ICU

□ POV # Days: ______

□ Public transportation (bus, taxi, etc.) □ Admitted to unmonitored ward

□ On foot # Days: ______

□ Other: __________________________

Initial Vital Signs: Height: _________ □ cm □ in Weight: ________ □ kg □ lb

Temp (°F): ________ Heart Rate: _______ Respiratory Rate: _______ BP (mmHg): ______ / _______

O2 sat: ________ Supplemental O2? □ Y □ N □ N/A If yes, delivery method: ______________________

Medical History (check all that apply)

□ Asthma □ Congestive heart failure Medications:

□ COPD □ Breastfeeding _____________________________________________

□ Depression □ Pregnant

□ Diabetes □ Tobacco use _____________________________________________

□ GERD (Reflux) □ Other: _______________________

□ Hypertension ______________________________ _____________________________________________

□ Malignancy ______________________________

□ Myocardial infarction ______________________________ _____________________________________________


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Public reporting burden of this collection of information is estimated to average 30 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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX)


Signs and Symptoms

Check box if sign or symptom is present in the medical record (for this encounter). If date of onset is different from date of presentation, indicate in date column.



Sign/Symptom Date

General

□ Chills ___ / ___ / ____

□ Fever (>100.4 °F) ___ / ___ / ____

□ Fatigue/Malaise ___ / ___ / ____

□ Hypothermia (<95.0 °F) ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Eye

□ Corneal abrasion ___ / ___ / ____

□ Increased tearing ___ / ___ / ____

□ Irritation/Pain ___ / ___ / ____

□ Itching/Pruritis ___ / ___ / ____

□ Miosis ___ / ___ / ____

□ Mydriasis ___ / ___ / ____

□ Visual changes ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Cardiovascular

□ Bradycardia ___ / ___ / ____

□ Cardiac arrest ___ / ___ / ____

□ Chest pain ___ / ___ / ____

□ Hypertension ___ / ___ / ____

□ Hypotension ___ / ___ / ____

□ Palpitations ___ / ___ / ____

□ Tachycardia ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Respiratory

□ Chest tightness ___ / ___ / ____

□ Cough ___ / ___ / ____

□ Cyanosis ___ / ___ / ____

□ Dyspnea/ SOB ___ / ___ / ____

□ Hyperventilation/Tachypnea ___ / ___ / ____

□ Lower airway pain/irritation ___ / ___ / ____

□ Nose bleed ___ / ___ / ____

□ Pleuritic chest pain ___ / ___ / ____

□ Phlegm/Congestion ___ / ___ / ____

□ Runny nose ___ / ___ / ____

□ Stridor ___ / ___ / ____

□ Upper airway pain/irritation ___ / ___ / ____

□ Wheezing ___ / ___ / ____ □ Other: __________________ ___ / ___ / ____





Sign/Symptom Date

Gastrointestinal

□ Abdominal pain ___ / ___ / ____

□ Anorexia ___ / ___ / ____

□ Constipation ___ / ___ / ____

□ Diarrhea ___ / ___ / ____

□ Nausea ___ / ___ / ____

□ Vomiting ___ / ___ / ____


Nervous System

□ Ataxia ___ / ___ / ____

□ Confusion ___ / ___ / ____

□ Dizzy/Vertigo ___ / ___ / ____

□ Fainting ___ / ___ / ____

□ Fasciculations ___ / ___ / ____

□ Headache ___ / ___ / ____

□ Hyperactive/anxiety/irritable ___ / ___ / ____

□ Lightheaded ___ / ___ / ____

□ Loss of balance ___ / ___ / ____

□ Memory loss ___ / ___ / ____

□ Muscle pain ___ / ___ / ____

□ Muscle rigidity ___ / ___ / ____

□ Muscle weakness ___ / ___ / ____

□ Paralysis ___ / ___ / ____

□ Peripheral neuropathy ___ / ___ / ____

□ Salivation ___ / ___ / ____

□ Tingling/Numbness ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Skin

□ Burns ___ / ___ / ____

□ Edema/Swelling ___ / ___ / ____

□ Erythema/Redness/Flushing ___ / ___ / ____

□ Hives/Welts ___ / ___ / ____

□ Irritation/Pain ___ / ___ / ____

□ Itching/Pruritis ___ / ___ / ____

□ Rash ___ / ___ / ____

□ Other: __________________ ___ / ___ / ___



Decontamination

Was the patient decontaminated? □ Yes □ No □ N/A How was the patient decontaminated? (check all that apply)

If yes, where was the patient decontaminated? □ Clothing removed

□ In the field/At site □ Water

□ At hospital □ Soap and water

□ Both □ N/A

□ N/A □ Other: __________________________________

□ Other: ___________________________


Imaging

Date

Type of Imaging

Location

Contrast

Acute Findings

Description of Acute Findings

___ / ___ / ____


□ X-ray

□ CT

□ MRI

□ Other:

____________________



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ CT

□ MRI

□ Other:

____________________



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ CT

□ MRI

□ Other:

____________________



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ CT

□ MRI

□ Other:

____________________



□ Y

□ N


□ Y

□ N



EKG

Date

Findings

Description of EKG Findings

___ / ___ / ____


□ WNL

□ Abnl, consistent

□ Abnl, new


___ / ___ / ____


□ WNL

□ Abnl, consistent

□ Abnl, new




WNL- within normal limits

Abnl, consistent- Abnormal finding, consistent with medical history or previous disease

Abnl, new- Abnormal finding, may indicate the presence of new disease

Lab Values (See key below for check box explanations)

(Only record actual value if it is initially abnormal or becomes abnormal. Do not record normal values.)

Lab


Repeat Lab Values (if necessary)

Na


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

K


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Cl


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

HCO3-


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

BUN


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Cr


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Glu


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Hgb


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Hct


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________



WBC


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Plts


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Ca2+


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

AST


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

ALT


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Total Bili


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Alk Phos


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Other:

_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Other:

_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Other:

_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Urinalysis


Date: ___ / ___ / ____

Repeat Lab Values (if necessary)

pH

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Specific Gravity

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Protein

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Glucose

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Ketones

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

WBC

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

RBC

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Bilirubin

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


WNL- Within normal limits

Abnl, CI- Abnormal, Clinically insignificant (To be determined with NCEH Toxicologists)

Abnl, C Dz- Abnormal finding, consistent with documented chronic disease

Abnl, exposure- Abnormal finding, potentially associated with the exposure

Abnl, other- Clinically significant abnormality, related to other disease process



Pulmonary Function Tests


Predicted Value

Measured Value

% Predicted

Forced Vital Capacity




Forced Expiratory Volume (FEV1)




FEV1/FVC




Peak Expiratory Flow Rate




Forced Inspiratory Vital Capacity




Forced Expiratory Flow





Arterial Blood Gas (ABG) Flow Sheet

Date

Date

Date

Date

Time

Time

Time

Time

pH

pH

pH

pH

pO2

pO2

pO2

pO2

pCO2

pCO2

pCO2

pCO2

HCO3-

HCO3-

HCO3-

HCO3-

O2 sat

O2 sat

O2 sat

O2 sat

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.


Medications (new medications that were initiated or prescribed during this visit/admission)

Name

Indication

Given during this visit?

Continued after discharge?






















Consults


□ Cardiology: _______________________________________________________________________________________

__________________________________________________________________________________________________

□ Dermatology: _____________________________________________________________________________________

__________________________________________________________________________________________________

□ ENT: ____________________________________________________________________________________________

__________________________________________________________________________________________________

□ Ophthalmology: ___________________________________________________________________________________

__________________________________________________________________________________________________

□ Pulmonary: _______________________________________________________________________________________

__________________________________________________________________________________________________

□ Poison Control: ___________________________________________________________________________________

__________________________________________________________________________________________________

□ Psychiatry: _______________________________________________________________________________________

__________________________________________________________________________________________________

□ Social Work: ______________________________________________________________________________________

__________________________________________________________________________________________________

□ Surgery: _________________________________________________________________________________________

__________________________________________________________________________________________________

□ Other: ___________________________________________________________________________________________

__________________________________________________________________________________________________


Outcomes


Primary Diagnosis: __________________________________________________________________________________



Secondary Diagnosis: ________________________________________________________________________________



ICD-9 Codes

1. ___________________ 2. _________________ 3. ____________________


4. ___________________ 5. _________________ 6. ____________________



Discharge


□ LWBS □ Discharged from ED: Date: ___ / ___ /____ Time: ____: _____ □ am □ pm

□ Admitted: ___ / ___ /____ Discharge information: Date: ___ / ___ /____ Time: ____: _____ □ am □ pm

□ Died: ___ / ___ /____ Cause of death: _________________________________________________________________

□ Other: ___________________________________


LWBS- Left without being seen


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