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pdf2018 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
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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
_______________________________________________________
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_______________________________________________________
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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:
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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:
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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 Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |