` Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Human Parechovirus 3 (HPeV3) Investigation
Part I: Medical Chart Abstraction
Please note that this medical chart review form has 19 pages and contains four parts:
Part A: demographic information about the infant who was ill with HPeV3
Part B: information from the medical chart of the mother for labor, delivery and follow up
Part C: information from the medical chart of the infant during delivery and neonatal care
Part D: information from the medical chart of the infant following admission for HPeV3 illness (most likely at Children’s Mercy Hospital)
Date of chart abstraction: ________________ (MM/DD/YYYY)
Name of person completing form: _________________________________________________________
Name and address of institution where this form was completed:
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Part A: HPeV3 case-patient information |
First Name: ____________________________ Last (Family) Name: _________________________ Date of Birth: __________________ (MM/DD/YYYY) Sex: Female Male Unknown Race: Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native White (More than one box can be checked) Ethnicity: Hispanic Non-Hispanic
First name of parent/guardian: _____________________________________ Last (Family) name of parent/guardian: ______________________________ Contact telephone number: ________________________________________ Email address: ___________________________________________________ Residence address: __________________________________________________________________ __________________________________________________________________________________
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Part B: Mother’s medical record for labor, delivery and follow up |
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Medical record number: _____________________________ Hospital name: _____________________________________________________________________ Hospital floor: ____________________ Hospital room number ______________________ Date mother was admitted to hospital: ______________________ (MM/DD/YYYY) Date of discharge: _____________________ (MM/DD/YYYY)
Mother’s First Name: ______________________________________ Mother’s Last (Family) Name: _______________________________ Mother’s date of birth: __________________ (MM/DD/YYYY) OR Mother’s age (yrs) ________ Mother’s race: Asian Black Hawaiian/Pacific Islander Native American/Alaskan White Other (More than one box can be checked) Mother’s ethnicity: Hispanic Non-Hispanic Mother’s telephone number (if different to Part 1): _______________________________________ Mother’s residence address (if different to Part 1): _________________________________________ __________________________________________________________________________________ Mother’s type of health insurance ______________________________________________________ Does the mother have any pre-existing medical conditions? Yes No Unknown
Date of delivery: _____________________ (MM/DD/YYYY) Time of delivery: _______________ Delivery ward: ______________________________________________________________________ Mode of delivery: Vaginal delivery Caesarean Section Unknown If vaginal, duration of membrane rupture prior to delivery (hours) ___________ Was a scalp monitor used during delivery? Yes No Unknown If yes, was there evidence of its use upon physical examination? Yes No Unknown (e.g. bruising, laceration)
Was the mother febrile (>38 °C) during delivery? Yes No Unknown Was the mother febrile (>38 °C) in the week before delivery? Yes No Unknown Did the mother have a rash during delivery? Yes No Unknown Did the mother have a rash in the week before delivery? Yes No Unknown If yes to any of the above, please include a description of the rash (eg location, type {maculopapular, vesicular} etc):
Please list any medications prescribed to the mother in hospital (e.g. PRN medications, oxytocin, antibiotics, anesthetics):
Please list staff present before and during labor or the delivery, and also post-partum care:
Any other comments regarding labor, delivery or post-partum care:
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Part C: Infant’s chart for delivery and neonatal follow up |
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Medical record number: _______________________ Hospital name: ______________________________________________________________________ Infant’s First Name: _______________________ ____ Infant’s Last (Family) Name: __________________________ Date of delivery: _________________ (MM/DD/YYYY) Time of delivery: ___________________ Length of gestation (weeks): _________ Infant’s Birth Weight (lbs): __________ Estimated Measured Unknown Was resuscitation required at birth? Yes No Unknown If yes: Suction Oxygen Positive pressure ventilation (PPV) Intubation Which nursery was the infant in after birth? _______________________________________________ How long was the infant in the nursery? ________ hours/days (please circle) Unknown
Please list any staff who cared for the infant in the nursery:
Please list any medications prescribed to the infant during neonatal care:
Please describe any treatment regimens or interventions provided to the infant during neonatal care (e.g. supplemental oxygen, respiratory therapy, supplemental feeding, circumcision, PRN meds etc):
Any other comments regarding the infant’s delivery or neonatal care:
Discharge date: __________________ (MM/DD/YYYY) Status upon discharge: ________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
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Part D: Medical chart of infant’s hospitalization for HPeV3 illness |
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Medical record number: __________________________________ Infant’s First Name: ______________________________________ Infant’s Last (Family) Name: _______________________________ Infant’s date of birth: __________________ (MM/DD/YYYY) Date of testing for HPeV: __________________(MM/DD/YYYY) Test type: ___________________________ Results: ________________________________ Admission date to hospital of initial presentation: ______________________ (MM/DD/YYYY) Transfer date from hospital of initial presentation: ______________________ (MM/DD/YYYY) Admission date to secondary facility: ______________________ (MM/DD/YYYY) Transferred from: Hospital name and nursery: ____________________________________________________________ Transferred to: Hospital name and nursery: ____________________________________________________________ Please describe any patient information available from a referring facility, if applicable:
Did the infant have any underlying medical conditions? Yes No Unknown
Are outpatient visits prior to becoming ill noted in the chart? Yes No Unknown
Is family history of neurologic illness, including seizures, noted in the chart? Yes No Unknown If yes, please describe:
Please list any medications prescribed to the infant before hospitalisation (e.g. OTC meds used by parents, medications discontinued prior to hospitalisation):
Signs and Symptoms Date of first clinical symptoms: ___________________ (MM/DD/YYYY) As part of this illness, does the infant have or has the infant had any of the following: Fever Fever (>38 °C)………………………………………………………….. Yes No Unknown If yes, what was the highest temperature? _______ °C Temperature <35 °C…….………………………………………….. Yes No Unknown If yes, what was the lowest temperature? _______ °C Rash Skin rash……..………………………………………………………….. Yes No Unknown If yes, please describe (eg. Location, type {maculopapular, vesicular} etc):_______________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Redness on feet or hands ………………………………………… Yes No Unknown Ulcers or lesions in mouth……………………………………….. Yes No Unknown Neurologic Focal seizures/convulsions…….……………………………. Yes No Unknown Generalized seizures/convulsions…….…………………….. Yes No Unknown Intractable seizures/convulsions…….…………………..….. Yes No Unknown Myoclonic jerk..………………………………………………………. Yes No Unknown Tremors.…………………………………………………………………. Yes No Unknown Limb weakness/monoparesis………………………………….. Yes No Unknown Stiff neck..……………………………………………………………….. Yes No Unknown Bulging fontanelle.………………………………………………….. Yes No Unknown Lethargy………………………………………………………………….. Yes No Unknown Irritability.……………………………………………………………….. Yes No Unknown Inconsolable crying…………………………………………………. Yes No Unknown Cranial nerve palsy………………………………………………….. Yes No Unknown
Respiratory Cough (dry, productive).….…………..………………………….. Yes No Unknown Secretions……………………………………………………………….. Yes No Unknown Runny nose.…………………………………………………………….. Yes No Unknown Sneezing………………………………………………………………….. Yes No Unknown Difficulty breathing………………………………………………….. Yes No Unknown Wheezing.……………………………………………………………….. Yes No Unknown Rales/crackles/crepitations.…………………………………….. Yes No Unknown Tachypnea (as assessed and recorded by provider)… Yes No Unknown If yes, please indicate rate ___________ (RR/min) Frothy secretions from mouth..……………………………….. Yes No Unknown Hemoptysis.…………………………………………………………….. Yes No Unknown Respiratory failure.………………………………………………….. Yes No Unknown Oxygen given.………………………………………………………….. Yes No Unknown If yes, how was it administered? _______________________________________________________ Intubation……………………………………………………………….. Yes No Unknown Retractions, nasal flaring..……………………………………….. Yes No Unknown
Cardiovascular Bradycardia (as assessed and recorded by provider).. Yes No Unknown If yes, please indicate rate ___________ (HR/min) Tachycardia (as assessed and recorded by provider).. Yes No Unknown If yes, please indicate rate ___________ (HR/min) Variable heart rate (tachy/brady)……………………………. Yes No Unknown Cyanosis………………………………………………………………….. Yes No Unknown Mottled skin……………………………………………………………. Yes No Unknown Arrhythmia.…………………………………………………….……….. Yes No Unknown Abnormal heart sounds.………………………………………….. Yes No Unknown If yes, please describe ________________________________________________________________ Hypotension/shock………………………………………………….. Yes No Unknown
Gastrointestinal Vomiting………………………………………………………………….. Yes No Unknown Watery stools………………………………………………………….. Yes No Unknown Constipation..………………………………………………………….. Yes No Unknown Abdominal distention.…………………………………………….. Yes No Unknown Abdominal pain……………………………………………………….. Yes No Unknown Jaundice………………………………………………………………….. Yes No Unknown Poor feeding………………………………………………………… .. Yes No Unknown
Others Conjunctivitis.………………………………………………………….. Yes No Unknown Bleeding.………………………………………………………………….. Yes No Unknown Persistent crying………………………………………………………. Yes No Unknown Lymphadenopathy.………………………………………………….. Yes No Unknown
Please describe any other symptoms not listed above, or any of note:
Laboratory Exams Please list here all laboratory findings from admission:
Radiologic Exams Please describe here all radiological exams requested:
Medication and Treatment Was the infant placed in the neonatal intensive care unit (NICU)? Yes No Unknown If yes, admission date: ________________ Discharge date: ________________ (MM/DD/YYYY) Was the infant placed in the pediatric intensive care unit (PICU)? Yes No Unknown If yes, admission date: ________________ Discharge date: ________________ (MM/DD/YYYY) Please list any medications prescribed to the infant in hospital:
Please describe any other treatment regimens or interventions provided to the infant in hospital (e.g. supplemental oxygen, respiratory therapy, supplemental feedings, PRN meds etc):
Discharge Is infant still in hospital? Yes No If no, discharge date: __________________(MM/DD/YYYY) Status upon discharge: ________________________________________________________________ Died: Yes No Unknown If yes, date of death ___________________ (MM/DD/YYYY) Discharge diagnosis: __________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Other information Please describe here any other information that you feel may be important or unusual, with regard to the infant’s stay in hospital:
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End of medical chart abstraction form
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 D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
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File Created | 2021-01-23 |