Appx 7 Veterinary Chart Abstraction Form SAMPLE

Appx 7 VetChartAbstrct Form_SAMPLE.docx

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

Appx 7 Veterinary Chart Abstraction Form SAMPLE

OMB: 0923-0051

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Appendix 7: Veterinary Chart Abstraction Form

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Form Approved

OMB No. 0923-XXXX

Exp. Date XX/XX/20XX

Veterinary Chart Abstraction Form

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

Veterinary Hospital: _______________________________ Pet ID: _________

Pet Name: _____________________________ Owner’s Name: ______________________________________

Address: Street: ___________________________ City: ___________________ State: _____ Zip: _____________

Telephone (Home) ______________(Cell) ______________(Work) ______________(Other) ______________

Patient Demographics

Age: ____ □ Years □ Months Sex: □ Male □ Female □ Neutered/Spayed

Species: □ Dog □ Cat □ Other _______________________ Breed: _______________________________

Hair Length: □ Short □ Medium □ Long □ Hairless □ N/A Body Condition Score: ____


Visit Information

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

MM DD YYYY

Chief Complaint: ___________________________________________________________________________________

Was the pet admitted? □ Y □ N If yes, # Days: ______

Initial Vital Signs: Weight: ________ □ kg □ lb

Temp (°F): ________ Heart Rate: _______ Respiratory Rate: _______ O2 sat: ________

Medical History


__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________



Medications: Heartworm prevention □ Y □ N

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________



Decontamination

Was the patient decontaminated? □ Yes □ No □ N/A

If yes, where was the patient decontaminated? How was the patient decontaminated?

□ In the field/At site □ Water

□ At veterinary hospital □ Soap and water

□ Both □ Other: ___________________________

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Public reporting burden of this collection of information is estimated to average 20 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)

□ Other: ________________________________


Clinical Signs

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


Sign Date

General

□ Fever (>103.0 °F)* ___ / ___ / ____

□ Hypothermia (<98.0 °F)* ___ / ___ / ____

□ Lethargy ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Eye

□ Corneal abrasion ___ / ___ / ____

□ Increased tearing ___ / ___ / ____

□ Irritation/Pain ___ / ___ / ____

□ Itching/Pruritis ___ / ___ / ____

□ Miosis ___ / ___ / ____

□ Mydriasis ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Cardiovascular

□ Bradycardia* ___ / ___ / ____

□ Cardiac arrest ___ / ___ / ____

□ Hypertension ___ / ___ / ____

□ Hypotension ___ / ___ / ____

□ Tachycardia* ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Respiratory

□ Cough ___ / ___ / ____

□ Cyanosis ___ / ___ / ____

□ Dyspnea ___ / ___ / ____

□ Hyperventilation/Tachypnea ___ / ___ / ____

□ Nose bleed ___ / ___ / ____

□ Phlegm/Congestion ___ / ___ / ____

□ Runny nose ___ / ___ / ____

□ Stridor ___ / ___ / ____

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

Gastrointestinal

□ Abdominal pain ___ / ___ / ____

□ Anorexia ___ / ___ / ____

□ Constipation ___ / ___ / ____

□ Diarrhea ___ / ___ / ____

□ Nausea ___ / ___ / ____

□ Vomiting ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____




Sign Date

Nervous System

□ Ataxia ___ / ___ / ____

□ Fasciculations ___ / ___ / ____

□ Hyperactive/anxiety/irritable ___ / ___ / ____

□ Muscle pain ___ / ___ / ____

□ Muscle rigidity ___ / ___ / ____

□ Muscle weakness ___ / ___ / ____

□ Paralysis ___ / ___ / ____

□ Peripheral neuropathy ___ / ___ / ____

□ Salivation ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Skin

□ Burns ___ / ___ / ____

□ Edema/Swelling ___ / ___ / ____

□ Erythema/Redness/Flushing ___ / ___ / ____

□ Hives/Welts ___ / ___ / ____

□ Irritation/Pain ___ / ___ / ____

□ Itching/Pruritis ___ / ___ / ____

□ Rash ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


*Normal value varies by species



Imaging

Date

Type of Imaging

Location

Contrast

Acute Findings

Description of Acute Findings

___ / ___ / ____


□ X-ray

□ Ultrasound

□ Other:

____________________



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ Ultrasound

□ Other:

____________________



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ Ultrasound

□ Other:

____________________



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ Ultrasound

□ 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




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

Supplemental O2

Y □ N □ N/Ac

Supplemental O2

Y □ N □ N/A

Supplemental O2

Y □ N □ N/A



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

Name

Indication

Given during this visit?

Continued after discharge?






















Outcomes


Diagnosis: _________________________________________________________________________________________


Discharge


□ LWBS □ Office visit

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

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

Necropsy performed? □ Yes □ No □

If yes, where? _______________________________________________________________________________

Necropsy findings: ___________________________________________________________________________

__________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

□ Other: ___________________________________


LWBS- Left without being seen


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