Appx 7 Veterinary Chart Abstraction Form SAMPLE

Appendix 7: Veterinary Chart Abstraction Form

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: ___________________________

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