A
ppendix
1: Chart Abstraction Form
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Patient Name: ________________________________________________________
CDC ID#:____________________________________________________________
Chart Abstraction Form
Name of Person Completing Form _____________________________ Date: ____/_____/____
Case Control: Matched to case (CDC ID): _______
Date of onset/positive culture (for case or matched control): _______________
30day window period: ________ to _________ 7day window period: _________ to _________
Demographic Information
Sex: Male Female Age (specify years or months if <2 years):________________
Race: White Black Asian American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander Other____________
Ethnicity: Hispanic/Latino Non-Hispanic/Latino
Birth History
Gestational age: ____ wks ____ days Birth weight: ______ grams or _____lbs.____oz.
Birth: C-section Vaginal delivery Multiple birth APGAR: 1min____ 5 min____
Maternal/ Obstetric History: G____P____
Chorioamnionitis
Cigarette smoking
Drug use:_____________
Fetal distress
Gestational diabetes
IUGR
Maternal infection
Preeclampsia
Premature delivery
PROM
Unknown
Other______________
Medical History
1. Comorbidities: Unknown
Aspiration
Gastric residual >30%
Intracran. hemorrhage
Patent ductus arteriosis
Perinatal asphyxia
Reflux/ Regurgitation
Sepsis
Cardiac abnormalities (e.g., congenital heart disease): _________________________________
Pulmonary disease (e.g., BPD, HMD/RDS, meconium aspiration): ______________________
Gastointestinal disease (e.g., NEC, gastroschisis, omphalocele): _______________________
Other: _________________________________________________________________________
2. Did infant have any of the following 7 days prior to positive culture? Unknown
GI surgery Non GI surgery Retinopathy of prematurity (ROP) treatment
Mechanical ventilation Umbilical catheter Other central venous catheter
Oro/nasogastric tube G-tube Jejunal tube
RBC transf: (Date: ________, # units:____) Supplemental O2
Other devices (describe): ___________________________________________________________
Medication History
Was infant treated with antimicrobial 30 days before onset/positive culture?
Yes No Unk.
Antimicrobial |
Route |
Start Date |
Stop Date |
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Other medications received 7 days prior to onset or positive culture?
Medication |
Route |
Start Date(s) |
Stop Date(s) |
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Other injectables received in the 7 days before onset or positive culture?
Product |
Start Date(s) |
Stop Date(s) |
TPN Yes No Unk |
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Illness History: Please fill out for case-patients only
1. Date of onset/positive culture: ____/___ /____
2. Outcome (include date):
Ongoing illness Symptoms resolved__________ Colonization only ____________ Death____________ Unknown
If death, attributed to Pseudomonas? Yes No Autopsy performed? Yes No
3. Pathology results from surgery or autopsy: ____________________________________________
___________________________________________________________________________
4. Pathology samples from surgery or autopsy available? Yes No
H. Clinical Information: Please fill out for case-patients only
1. Signs and Symptoms within 48 hours of onset or positive culture (check all that apply):
Unk.
Fever
Sepsis
Tachycardia/ Rapid heart rate
Tachypnea/Rapid breathing
Other________________
________________________________________________________________________
2. Abnormal laboratory findings within 48 hours of onset or positive culture (check all that apply):
Unk.
Anemia: Hb______, Hct______
Coagulopathy: INR_______, PTT_____
Leukocytosis: WBC______
Metabolic acidosis: pH_____, HCO3___
Neutropenia: WBC______, ANC______
Thrombocytopenia: Plt ______
3. Microbiology findings: List all positive cultures from sterile sites (blood, urine, etc.) and surveillance culture sites
(Date range: 1 week prior to illness onset until resolution of illness)
No cultures drawn All cultures negative Unknown
Date |
Source |
Organism |
# Positive Bottles (x/y) |
Surveillance culture?(Y/N) |
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Bathing/skin care history
Skin care products used |
Brand/Manufacturer |
Dates |
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Oral care products
Oral care products used |
Brand/Manufacturer |
Dates |
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Staff exposures
Staff |
Role |
Dates |
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L. Notes/Remarks (Anything unusual about hospital course not included above, including patterns of medication/thickener use, patient course at home, etc.)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
K. Medical Chart Abstraction Form Complete?
Yes---- date of completion _____/_____/_____
No
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 D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | iym6 |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |