Chart Abstraction Form

Appendix 1. Chart Abstraction Form.pdf

Emergency Epidemic Investigation Data Collections - Expedited Reviews (Y3Q4)

Chart Abstraction Form

OMB: 0920-1011

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2018 CHART ABSTRACTION FORM
Patient information (remove top page following abstraction)

PATIENT ID ___ ___ ___ ___ ___

Patient’s Name:
First Name

Last Names
Date of Birth:

_______/_______/_______
MM

DD

Abstractor initials:

YYYY

FINAL

1

2018 CHART ABSTRACTION FORM
PATIENT ID ___ ___ ___ ___ ___
Gender:

I. Patient data

M

F

_______/_______/_______

Date of Birth:

MM

DD

YYYY

Tribal affiliation:

Tribal community:

II. Chart abstraction info
Abstractor initials:

Date of chart abstraction: _______/_______/_______
MM

DD

YYYY

Location of primary abstraction:

III. Dates of care
Not available

_______/_______/_______

Date of first symptoms:

MM

Date of fever onset (if different):

DD

Symptoms at first provider visit:

YYYY

_______/_______/_______
MM

DD

YYYY

_______/_______/_______

Date of first provider visit:

MM

DD

ICD-9 or ICD-10 codes used at first provider visit:

YYYY

Tick bite or tick contact noted in first visit?
Healthcare facilities visited during RMSF illness:
Name of facility

Dates of care

MM

DD

MM

DD

MM

DD

To: _______/_______/_______
MM

YYYY

DD

From: _______/_______/_______

To: _______/_______/_______

DD

MM

DD

MM

YYYY

MM

DD

DD

DD

MM

DD

DD

MM

YYYY

_______/_______/_______
MM

DD

YYYY

_______/_______/_______
MM

DD

YYYY

YYYY

To: _______/_______/_______

YYYY

Date of first RMSF mention in chart:_______/_______/_______
MM

YYYY

To: _______/_______/_______

YYYY

From: _______/_______/_______
MM

DD

MM

YYYY

From: _______/_______/_______

Date of fever resolution:

YYYY

From: _______/_______/_______
MM

Date of first tetracycline therapy:

YYYY

To: _______/_______/_______

No

Unk

To: _______/_______/_______

YYYY

From: _______/_______/_______

Yes

No

Type of visit (ED, outpatient, inpatient)

From: _______/_______/_______

Admitted to ICU?

Yes

YYYY

DD

YYYY

Number of ER visits: _____
Number of outpatient visits: _____
Number of general admission days : _____
Number of ICU days : _____

IV. Medical history prior to hospitalization (check if yes)
Diabetes

Hx of drug abuse

Hx of alcohol abuse

V. Medical history during hospitalization (check if yes)
Evidence of shock or use of vasopressors

Cerebral edema

ARDS

Coma

Multiorgan failure
Renal insufficiency

Altered mental status
Digital necrosis
If yes, specify body parts involved:
_______________________________________
_______________________________________
_______________________________________
_______________________________________

Severe thrombocytopenia(<50 103 uL)
If yes, list date of first result <50 103 uL

_______/_______/_______
MM

DD

YYYY

Rash and/or eschar
If yes, please describe onset (including dates), location,
and evolution
_______________________________________________________

2

_______________________________________________________
_______________________________________________________
_______________________________________________________

2018 CHART ABSTRACTION FORM
PATIENT ID ___ ___ ___ ___ ___

VI. Treatment and procedures during hospitalization
Antibiotic (including tetracycline therapy)

Start date

End date

______/______/______

______/______/______
MM

DD

______/______/______
MM
DD
YYYY
______/______/______

______/______/______
MM
DD
YYYY
______/______/______

DD

DD

to

DD

Mechanical Ventilation (eg. Intubation)

______/______/______

From

MM

DD

______/______/______
MM

YYYY

to

DD

DD

DD

MM

YYYY

Date1

______/______/______

YYYY

MM

YYYY

DD

DD

Date2

YYYY

YYYY

From

YYYY

______/______/______
MM

DD

YYYY

______/______/______
MM

Hemodialysis (e.g. CRRT)

______/______/______
MM

YYYY

MM

YYYY

Transfusion (products an quantity:__________________________________________)

Vassopressors (which:_______________________________________________)
MM

YYYY

______/______/______

MM

______/______/______

DD

______/______/______

MM

From

MM

YYYY

to

DD

YYYY

______/______/______
MM

DD

YYYY

Other surgical procedures

Amputation

Describe: ________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

If yes, specify body parts involved:
____________________________________________________________________________

VII. Neurologic and psychiatric history prior to RMSF
Did patient have any documented neurologic impairments(including concussion or TBI, fetal alcohol syndrome, Parkinson’s, etc.) prior to RMSF illness?
Yes

No

Unknown

If yes, specify type: __________________________________________________________________________________________________________________________________________
Date of diganosis

______/______/______
MM

DD

YYYY

Unknown

Did patient have any documented psychiatric impairments prior to RMSF illness?
Yes

No

Unknown

If yes, specify type: __________________________________________________________________________________________________________________________________________
Date of diganosis

______/______/______
MM

DD

YYYY

Unknown

For children <8 years, were there any previously documented developmental delays noted prior to RMSF illness?
Yes

No

Unknown

If yes, describe: __________________________________________________________________________________________________________________________________________

VIII. Neurologic and psychiatric history at discharge
YES NO Unknown
Behavioral/personality change
Memory problems
Anxiety
Depression
Confusion/disorientation/coma
Headache
Pain
Dysarthria/slurred speech
Dysphagia/difficulty swallowing
Hearing loss
Blindness/visual impairment
Diplopia/ophthalmoplegia

YES NO Unknown
Numbness/paresthesias
Myoclonus
Seizures
Bowel/bladder incontinence
Weakness
Difficulty breathing
Tremors
Ataxia/problems with balance
Hyporeflexia/areflexia
Decline in functional capacity from baseline
If yes, describe:

3

_______________________________________________________________________________________
_______________________________________________________________________________________

2018 CHART ABSTRACTION FORM
PATIENT ID ___ ___ ___ ___ ___

IX. RMSF Testing

_______/_______/_______

Specimen type: ______________________

MM

Specimen type: ______________________

DD

YYYY

Test: ______________________

Result: ______________________

Test: ______________________

Result: ______________________

Test: ______________________

Result: ______________________

Test: ______________________

Result: ______________________

Test: ______________________

Result: ______________________

_______/_______/_______
MM

Specimen type: ______________________

DD

YYYY

_______/_______/_______
MM

DD

YYYY

_______/_______/_______

Specimen type: ______________________

MM

DD

YYYY

_______/_______/_______

Specimen type: ______________________

MM

DD

YYYY

X. Other infectious etiology testing
Was a secondary infection documented (discharge summary, chart, labs)?
No

Yes

Unknown

If yes, please describe the nature of the infection and corroborating laboratory evidence:
_________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________

XI. Lumbar puncture (leave blank if not performed)

_______/_______/_______

Note, if multiple LPs were performed please use earliest result
WBCs/mm3

________________________

MM

Protein (mg/dL)

DD

YYYY

________________________

WBC diff: ____%PMN ____%Lymp ____%Eos ____%Mon

Glucose (mg/dL)________________________

RBCs/mm3________________________

Culture

Gram stain

________________________

Color (eg.xanthochromia)______________

________________________

XII. Neurologic and imaging studies:
Performed

Date of finding

Not performed

Impression (if unremarkable, write “normal”)

_______/_______/_______

Head CT

MM

DD

YYYY

List substantial changes in subsequent series:
_______________________________________________________________________________
_______________________________________________________________________________

Head MRI

_______/_______/_______
MM

DD

YYYY

List substantial changes in subsequent series:
_______________________________________________________________________________
_______________________________________________________________________________

_______/_______/_______

Spinal MRI

MM

Specify: _______________________

DD

YYYY

List substantial changes in subsequent series:
_______________________________________________________________________________
_______________________________________________________________________________

EEG or other
neurologic study

_______/_______/_______

Specify: _______________________

MM

DD

YYYY

List substantial changes in subsequent series:

4

_______________________________________________________________________________
_______________________________________________________________________________

2018 CHART ABSTRACTION FORM
PATIENT ID ___ ___ ___ ___ ___

XIII. Outcome
Final disposition:
Died
Date of death:

_______/_______/_______
MM

DD

YYYY

Transferred to another facility
Date of transfer:

_______/_______/_______

Type of facility:

MM

DD

Date of discharge, if known:

_______/_______/_______
MM

YYYY

DD

YYYY

Name of facility: ___________________________________

Acute rehabilitation
Sub-acute rehabilitation
Skilled nursing/long term care
Hospice
Other: __________________________
Home
Date of discharge:

_______/_______/_______
MM

DD

YYYY

Was patient referred for any of the following supportive care at discharge?
For each type of supportive care note referral status and list length of referral (days)
Physical therapy

Yes

No

Unknown

_______ days

Occupational therapy

Yes

No

Unknown

_______ days

Speech therapy

Yes

No

Unknown

_______ days

Behavioral therapy

Yes

No

Unknown

_______ days

Other, please describe

XIIII. Modified Rankin Scale at discharge (based on discharge summary) use pediatric modified Rankin for children less than 8 years of
age

0 = No symptoms at all
1 = No significant disability despite symptoms; able to carry our all usual duties and activities
2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs
without assistance
3 = Moderate disability; requiring some help, but able to walk without assistance
4 = Moderately severe disability; unable to walk without assistance and unable to attend to
own bodily needs without assistance
5 = Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 = Dead

SCORE (0 – 6):

_____________

Additional notes from previous sections (please note page number, section and item continued)

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File Typeapplication/pdf
File TitleSlide 1
AuthorLWaller
File Modified2018-07-11
File Created2018-07-11

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