Risk Factor - Chart Abstraction - CDC

13. Risk Factor_ChartAbstraction0408_Instrument_OMB.docx

SARS-CoV-2 Epidemiologic Data Collections

Risk Factor - Chart Abstraction - CDC

OMB: 0920-1297

Document [docx]
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……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………

Patient first name _______________ Patient last name __________________ Date of birth (MM/DD/YYYY): ____/_____/_______

……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………


C OVID-19 Case Chart Abstraction Form



Shape2 Shape1 Record ID: CO_______________________ EIP ID (if available): _________________


Abstractor information

Name of abstractor: Last ______________________________ First______________________________________

Affiliation/Organization: ____________________________________________

Telephone ______________________________ Email _______________________________________________

Date of medical chart abstraction: _________________ (MM/DD/YYYY)

Data sources used for this form?

CORHIO CEDRS EIP Chart Abstraction Other source, specify:__________________________________


Was this case-patient hospitalized? Yes No


Hospitalization

  1. Hospital name: ____________________________________________________ Hospital phone: _____________________________

  2. Admission date 1 ___/___/___ (MM/DD/YYYY) , discharge date 1 ___/___/____ (MM/DD/YYYY) Patient still hospitalized

  3. Was their COVID-19 illness the initial reason for hospitalization? Yes No Unknown

If no, what was the non-COVID-19 reason for hospitalization: ___________________________________________________

  1. To where was the patient discharged?

Home Home with services Transferred to another hospital LTCF Acute Rehab Hospice Deceased

Homeless Incarcerated Other ______________ Unknown


  1. If hospitalized more than once, please enter the second hospitalization’s admission and discharge dates: [if there are more than two hospitalizations please use the notes section]

Hospital name 2: ____________________________________________________ Hospital phone 2: _____________________________

Admission date 2 ______/_____/_______ (MM/DD/YYYY) Discharge date 2______/_____/_______ (MM/DD/YYYY)

Patient still hospitalized

  1. To where was the patient discharged from hospital 2?

Home Home with services Transferred to another hospital LTCF Acute Rehab Hospice Deceased

Homeless Incarcerated Other ______________ Unknown


  1. Symptom onset date: _______/______/_________ (MM/DD/YYYY)


  1. Did the patient report any of the following symptoms occurring prior to presentation?

Symptom

Symptom Present?

Date of Onset (MM/DD/YY)

Fever >100.4F (38C)

Yes No Unknown


Highest temp________ °F



Subjective fever (felt feverish)

Yes No Unknown


Chills

Yes No Unknown


Sweats

Yes No Unknown


Dehydration

Yes No Unknown


Cough (new onset or worsening of chronic cough)

Yes No Unknown


Dry

Yes No Unknown


Productive

Yes No Unknown


Bloody sputum (hemoptysis)

Yes No Unknown


Sore throat

Yes No Unknown


Wheezing

Yes No Unknown


Shortness of breath (dyspnea)

Yes No Unknown


Runny nose (rhinorrhea)

Yes No Unknown


Stuffy nose (nasal congestion)

Yes No Unknown


Loss of smell (Anosmia)

Yes No Unknown


Loss of taste (Ageusia)

Yes No Unknown


Swollen Lymph Nodes (Lymphadenopathy)

Yes No Unknown


Eye redness (conjunctivitis)

Yes No Unknown


Rash

Yes No Unknown


Abdominal pain

Yes No Unknown


Vomiting

Yes No Unknown


Nausea

Yes No Unknown


Loss of appetite (anorexia)

Yes No Unknown


Diarrhea (>3 loose stools/day)

Yes No Unknown


Chest Pain

Yes No Unknown


Muscle aches (myalgia)

Yes No Unknown


Joint Pain (Arthralgia)

Yes No Unknown


Headache

Yes No Unknown


Fatigue

Yes No Unknown


Seizures

Yes No Unknown


Altered Mental Status (confusion)

Yes No Unknown


Other, specify:

Yes No Unknown


Other, specify:

Yes No Unknown


Other, specify:

Yes No Unknown


Other, specify:

Yes No Unknown



  1. List any medication that the individual taking prior to admission.

No medication listed; Reported not taking any medications prior to admission

Medication Name

Route

Frequency

Taking prior to illness onset?


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________

**If more than 6 medications listed by patient please fill out additional medication section at the end of the questionnaire.


  1. First recorded vital signs (AT PRESENTATION, e.g. IN THE ED FOR HOSPITALIZED CASES): Temp_________ (Unit: °F / oC)

Heart rate: _________ Resp rate:___________ Blood pressure: ________ mmHg (systolic) / ________ mmHg (diastolic)

O2 Sat: _______________

Type of support required when O2 saturation was measured:

Room Air Nasal Cannula Face Mask CPAP or BIPAP High Flow Nasal Cannula Invasive mechanical ventilation

Other, specify: ________________________________________ Unknown

Fraction of Inspired Oxygen/Flow ___________ % Liters/minute (LPM) Unknown NA

Height (in cm): _________ Weight (in kg): __________ BMI (if recorded in medical records): _____________


  1. Lung exam normal: Yes No Unknown

If abnormal lung exam, describe: _______________________________________________________________________________________

  1. Admitting Diagnoses

Admitting Diagnosis

ICD-10-CM Code

1.


2.


3.



  1. Did the patient have any of the following pre-existing medical conditions? (select all that apply)

Chronic Lung Diseases

Yes

No

Unknown

Asthma/reactive airway disease

Yes

No

Unknown

Emphysema/Chronic Obstructive Pulmonary Disease (COPD)/Chronic Bronchitis

Yes

No

Unknown

Interstitial lung disease

Yes

No

Unknown

Pulmonary fibrosis

Yes

No

Unknown

Restrictive lung disease

Yes

No

Unknown

Sarcoidosis

Yes

No

Unknown

Cystic Fibrosis

Yes

No

Unknown

Chronic hypoxemic respiratory failure with O2 requirement (Do you use oxygen at home?)

Yes

No

Unknown

Obstructive sleep apnea (OSA)

Yes

No

Unknown

Other chronic lung disease

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Active tuberculosis

Yes

No

Unknown

Cardiovascular (CV) diseases

Yes

No

Unknown

Hypertension (high blood pressure)

Yes

No

Unknown

Coronary artery disease (heart attack)

Yes

No

Unknown

Heart failure/Congestive heart failure

Yes

No

Unknown

Cerebrovascular accident/Stroke

Yes

No

Unknown

Congenital heart disease (childhood heart problem)

Yes

No

Unknown

Valvular Heart Disease (abnormal heart valve[s] – e.g., aortic stenosis, mitral regurgitation)

Yes

No

Unknown

Arrhythmia (abnormal/irregular heartbeat or rhythm)

Yes

No

Unknown

Other CV disease (e.g. peripheral artery disease, aortic aneurysm, cardiomyopathy, or other heart or vessel diseases specified by the patient)

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Endocrine disorders

Yes

No

Unknown

Diabetes Mellitus (DM)

Yes

No

Unknown

If yes, specify DM Type 1 or 2

Yes

No

Unknown

If yes, what last HgA1c? (Hemoglobin A1c or “A1c”)? ________________ Date (MM/YY)_______________

Unknown

Pre-diabetes

Yes

No

Unknown

If yes, what last HgA1c? (Hemoglobin A1c or “A1c”)? ________________ Date (MM/YY)_______________

Unknown

Other endocrine (hormone) disorder (e.g. pituitary problems, hyperthyroidism,

hypothyroidism, Addison’s disease, Cushing’s syndrome

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Renal diseases

Yes

No

Unknown

Chronic kidney disease/insufficiency

Yes

No

Unknown

End-stage renal disease

Yes

No

Unknown

Dialysis

Yes

No

Unknown

If yes, specify type: hemodialysis (HD) or peritoneal

HD

Peritoneal

Unknown

Other

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Liver diseases

Yes

No

Unknown

Alcoholic hepatitis

Yes

No

Unknown

Chronic liver disease

Yes

No

Unknown

Cirrhosis/End stage liver disease

Yes

No

Unknown

Hepatitis B, chronic

Yes

No

Unknown

Hepatitis C, chronic

Yes

No

Unknown

Non-alcoholic fatty liver disease (NAFLD)/NASH

Yes

No

Unknown

Other

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Autoimmune disorders

Yes

No

Unknown

Rheumatoid arthritis

Yes

No

Unknown

Systemic lupus

Yes

No

Unknown

Other

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Hematologic disorders

Yes

No

Unknown

Anemia

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Sickle cell disease

Yes

No

Unknown

Sickle cell trait

Yes

No

Unknown

Bleeding or clotting disorders

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Other hematologic (blood) disorders

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Immunocompromised Conditions

Yes

No

Unknown

HIV infection

Yes

No

Unknown

If yes, what was last CD4 Count? _______________________ Date (MM/YY)_________________________

Unknown

AIDS or CD4 count <200

Yes

No

Unknown

Solid organ transplant

Yes

No

Unknown

Stem cell transplant (e.g., bone marrow transplant)

Yes

No

Unknown

Leukemia

Yes

No

Unknown

Lymphoma

Yes

No

Unknown

Multiple myeloma

Yes

No

Unknown

Splenectomy/asplenia

Yes

No

Unknown

Other:

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Cancer

Yes

No

(skip to next section)

Unknown

(skip to next section)

If yes, what type of cancer? _______________________________________________________________________________________________

Year diagnosed? _________________________


Cancer treatment include any of the following? (If yes, specify what years you received treatment)

IV Chemotherapy

Yes

No

Unknown

Year(s): ________________________________

Oral chemotherapy (pills)

Yes

No

Unknown

Year(s): ________________________________

Radiation

Yes

No

Unknown

Year(s): ________________________________

Other: ___________________________________

Yes

No

Unknown

Year(s): ________________________________

Neurologic/neurodevelopmental disorder: do you have any diseases of the brain, spinal cord, or nerves?

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Psychiatric Diagnosis: do you have any mental health problems? (e.g. depression, bipolar disorder, anxiety disorder, schizophrenia)

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Other chronic diseases:

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________


  1. Did the patient develop any of the following symptoms during their hospitalization for this illness?

    Symptom

    Symptom Present?

    Date of Onset (MM/DD/YY)

    Fever >100.4F (38C)

    Yes No Unknown


    Highest temp________ °F



    Subjective fever (felt feverish)

    Yes No Unknown


    Chills

    Yes No Unknown


    Sweats

    Yes No Unknown


    Dehydration

    Yes No Unknown


    Cough (new onset or worsening of chronic cough)

    Yes No Unknown


    Dry

    Yes No Unknown


    Productive

    Yes No Unknown


    Bloody sputum (hemoptysis)

    Yes No Unknown


    Sore throat

    Yes No Unknown


    Wheezing

    Yes No Unknown


    Shortness of breath (dyspnea)

    Yes No Unknown


    Runny nose (rhinorrhea)

    Yes No Unknown


    Stuffy nose (nasal congestion)

    Yes No Unknown


    Loss of smell (Anosmia)

    Yes No Unknown


    Loss of taste (Ageusia)

    Yes No Unknown


    Swollen Lymph Nodes (Lymphadenopathy)

    Yes No Unknown


    Eye redness (conjunctivitis)

    Yes No Unknown


    Rash

    Yes No Unknown


    Abdominal pain

    Yes No Unknown


    Vomiting

    Yes No Unknown


    Nausea

    Yes No Unknown


    Loss of appetite (anorexia)

    Yes No Unknown


    Diarrhea (>3 loose stools/day)

    Yes No Unknown


    Chest Pain

    Yes No Unknown


    Muscle aches (myalgia)

    Yes No Unknown


    Joint Pain (Arthralgia)

    Yes No Unknown


    Headache

    Yes No Unknown


    Fatigue

    Yes No Unknown


    Seizures

    Yes No Unknown


    Altered Mental Status (confusion)

    Yes No Unknown


    Other, specify:

    Yes No Unknown


    Other, specify:

    Yes No Unknown


    Other, specify:

    Yes No Unknown


    Other, specify:

    Yes No Unknown


  2. If the patient had a fever during this hospitalization (from presentation onward), what was the first date without documented fever: _______/______/_________ (MM/DD/YYYY)


  1. Did the following events/complications occur in the course of hospitalization? As reported by a physician in the medical record (e.g., notes).

Shock

Yes

No

Unknown

Volume overload

Yes

No

Unknown

Pulmonary edema

Yes

No

Unknown

Congestive heart failure

Yes

No

Unknown

Cardiac arrhythmia

Yes

No

Unknown

Myocardial infarction

Yes

No

Unknown

Cardiac arrest

Yes

No

Unknown

New onset cardiomyopathy

Yes

No

Unknown

Myocarditis

Yes

No

Unknown

Viral pneumonia

Yes

No

Unknown

Acute Respiratory Distress Syndrome (ARDS)

Yes

No

Unknown

If yes to ARDS, date of first ARDS diagnosis: _____/______/________ (MM/DD/YYYY)



If yes to ARDS, severity:

Mild

Moderate

Severe

COPD exacerbation

Yes

No

Unknown

Asthma exacerbation

Yes

No

Unknown

Pulmonary embolism

Yes

No

Unknown

Gastrointestinal hemorrhage

Yes

No

Unknown

Pancreatitis

Yes

No

Unknown

Liver dysfunction

Yes

No

Unknown

Acute kidney injury

Yes

No

Unknown

Acute interstitial nephritis

Yes

No

Unknown

Acute tubular necrosis

Yes

No

Unknown

Meningitis/Encephalitis

Yes

No

Unknown

Seizures

Yes

No

Unknown

Stroke/Cerebrovascular accident CVA

Yes

No

Unknown

Coagulation disorder/Disseminated Intravascular Coagulation (DIC)

Yes

No

Unknown

Hemophagocytic syndrome

Yes

No

Unknown

Deep vein thrombosis (DVT)

Yes

No

Unknown

Rhabdomyolysis

Yes

No

Unknown

Myositis

Yes

No

Unknown

Ventilator-acquired pneumonia (VAP)

Yes

No

Unknown

Hospital-acquired pneumonia (HAP)

Yes

No

Unknown

Multisystem organ failure

Yes

No

Unknown

Sepsis

Yes

No

Unknown

Bacterial co-infection

Yes

No

Unknown

If Yes, specify: ________________________________________________________________________________________________

Viral co-infection

Yes

No

Unknown

If Yes, specify: ________________________________________________________________________________________________

Fungal co-infection

Yes

No

Unknown

If Yes, specify: ________________________________________________________________________________________________







  1. During hospitalization, did the patient EVER receive...



Start Date (MM/DD/YYYY)

End Date (MM/DD/YYYY)

(leave blank if still receiving)

Total Days

Supplemental Oxygen via facemask?

Y N Unk




Supplemental Oxygen via low flow nasal cannula?

Y N Unk




High flow nasal cannula?

Y N Unk




Non-invasive ventilation (e.g., BiPaP)?

Y N Unk




Invasive mechanical ventilation (MV)?

Y N Unk




If yes to MV, highest FiO2

_________________



If yes to MV, lowest SpO2 at highest FiO2

_________________ %



If available, lowest SaO2 at highest FiO2

_________________ %



ECMO?

Y N Unk




Vasopressors? (ONLY if used to treat septic shock and not sedation-induced hypotension)

Y N Unk




If yes, which vasopressor(s)? (choose all that apply)

Dopamine Dobutamine Phenylephrine

Norepinephrine Epinephrine Vasopressin

NEW dialysis?

Y N Unk




If yes, was dialysis recommended to continue at discharge?

Y N Unknown

Patient died during hospitalization Patient still hospitalized

Cardiopulmonary Rescuscitation (CPR)?

Y N Unk

Date (of last attempt if multiple): _________/_________/___________

Neuromuscular blocking agents?

Y N Unk




Prone positioning?

Y N Unk




Tracheostomy inserted?

Y N Unk




Plasmapherisis?

Y N Unk




IVIG?

Y N Unk





  1. Was the patient admitted to an intensive care unit (ICU)? Yes No Unknown

ICU admission date 1 ______/_____/_______ (MM/DD/YYYY) ICU discharge date 1 ______/_____/_______ (MM/DD/YYYY) still in ICU

ICU admission date 2 ______/_____/_______ (MM/DD/YYYY) ICU discharge date 2 ______/_____/_______ (MM/DD/YYYY) still in ICU


  1. For patients who were admitted to the intensive care unit (ICU): fill out the Sequential Organ Failure Assessment (SOFA) for each day in the ICU. If multiple values are available for a parameter for a given day, fill in the most abnormal value.

For the MAP (mean arterial pressure) OR administration of vasoactive agents required, please fill in A-E as follows:

  1. Not hypotensive

  2. MAP < 70 mmHg

  3. DOPamine 5 ug/kg/min OR DOBUTamine (any dose)

  4. DOPamine > 5 ug/kg/min OR EPINEPHrine ≤ 0.1 ug/kg/min OR norepinephrine ≤ 0.1 ug/kg/min

  5. DOPamine > 15 ug/kg/min OR EPINEPHrine > 0.1 ug/kg/min OR norepinephrine > 0.1 ug/kg/min

For creatinine, mg/dL (umol/L) or urine output, please fill in A-E as follows:

  1. <1.2 (<110)

  2. 1.2-1.9 (110-170)

  3. 2.0-3.4 (171-299)

  4. 3.5-4.9 (300-400) OR UOP <500 mL/day

  5. 5.0 (>440) OR UOP <200 mL/day

Date (MM/DD/YYYY)








PaO2 (mmHg)








FiO2 (0-1)








Is pt on MV?

Y N

Y N

Y N

Y N

Y N

Y N

Y N

PLT (10^3/uL)








GCS








Bilirubin (mg/dL)








MAP OR vasoactive agents required








Creatinine or UOP








*If more than 7 days in the ICU use additional SOFA tables at end of form


  1. QTc from final available EKG: _________ seconds


  1. Clinical Discharge Diagnoses and ICD10 Discharge Codes

Clinical Discharge Diagnoses

ICD-10-CM Code

1.


2.


3.


4.


5.


6.


7.


8.


9.


10.



  1. Was the patient discharged on any type of oxygen support? Yes No Unknown Patient died during hospitalization

Type of oxygen support: Intermittent NC Continuous NC Trach with intermittent oxygen Trach with continuous oxygen


  1. List any medications listed in discharge summary in the table below: No medications at discharge

Medication Name

Route

Frequency


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________


Laboratory Data

  1. First recorded laboratory values for:

Test


Date of Collection (MM/DD/YYYY)

Value

Hematology CBC

Not performed



WBC (10^9/L)

Not performed



Differential

Not performed



% Segmented neutrophils

Not performed



% Bands

Not performed



% Lymphocytes

Not performed



% Monocytes

Not performed



% Eosinophils

Not performed



% Basophils

Not performed



Absolute neutrophil count (10^3/mcL)

Not performed



Absolute lymphocyte count (10^3/mcL)

Not performed



Absolute eosinophils count (10^3/mcL)

Not performed



Hemoglobin (Hg) (gm/dL)

Not performed



Hematocrit (Hct) (%)

Not performed



Platelet Count (cells/mm3)

Not performed



ANC (cells/mm3)

Not performed



Ferritin (mg/mL)

Not performed



Chemistry - CMP/Chem 12

Not performed



Sodium (meq/L)

Not performed



Potassium (meq/L)

Not performed



Chloride (mmol/L)

Not performed



CO2 (mmol/L)

Not performed



Calcium (mg/dL)

Not performed



Phosphate (mg/dL)

Not performed



Magnesium (mg/dL)

Not performed



Glucose (mg/dL)

Not performed



BUN (mg/dL)

Not performed



Creatinine (mg/dL)

Not performed



AST (U/L)

Not performed



ALT (U/L)

Not performed



Alkaline Phosphatase (ALP) (U/L)

Not performed



Total Bilirubin (mg/dL)

Not performed



Total protein (g/dL)

Not performed



Albumin (g/L)

Not performed



Lactate dehydrogenase (LDH) (U/L)

Not performed



Creatinine Kinase (CK) (U/L)

Not performed



Blood Gas

Not performed


ABG VBG

pH

Not performed



pCO2 (mmHg)

Not performed



pO2 (mmHg)

Not performed



HCO3 (mmol/L)

Not performed



Base Excess (mmol/L)

Not performed



If ABG, O2 Sat

Not performed



If ABG, FiO2

Not performed



Coagulation Panel

Not performed



PT (seconds)

Not performed



PTT (seconds)

Not performed



INR

Not performed



D dimer (mcg/mL)

Not performed



Fibrinogen

Not performed



Cardiac Biomarkers

Not performed



Troponin (ng/mL)

Not performed



BNP (pg/mL)

Not performed



Sepsis/Inflammatory Markers

Not performed



Lactate (mmol/L)

Not performed



Procalcitonin (ng/mL)

Not performed



CRP (mg/L)

Not performed



IL6 (pg/mL)

Not performed



Microbiology

Not performed



Rapid Strep (pos/neg)

Not performed



Legionella Urine Antigen

Not performed



Galactomannan

Not performed



Blood Bank

Not performed



Blood Type

Not performed



Rh status

Not performed




  1. Most abnormal laboratory values for: No additional labs performed

Test


Date of Collection (MM/DD/YYYY)

Value

Hematology CBC

Not performed



WBC (10^9/L)

Not performed



Differential

Not performed



% Segmented neutrophils

Not performed



% Bands

Not performed



% Lymphocytes

Not performed



% Monocytes

Not performed



% Eosinophils

Not performed



% Basophils

Not performed



Absolute neutrophil count (10^3/mcL)

Not performed



Absolute lymphocyte count (10^3/mcL)

Not performed



Absolute eosinophils count (10^3/mcL)

Not performed



Hemoglobin (Hg) (gm/dL)

Not performed



Hematocrit (Hct) (%)

Not performed



Platelet Count (cells/mm3)

Not performed



ANC (cells/mm3)

Not performed



Ferritin (mg/mL)

Not performed



Chemistry - CMP/Chem 12

Not performed



Sodium (meq/L)

Not performed



Potassium (meq/L)

Not performed



Chloride (mmol/L)

Not performed



CO2 (mmol/L)

Not performed



Calcium (mg/dL)

Not performed



Phosphate (mg/dL)

Not performed



Magnesium (mg/dL)

Not performed



Glucose (mg/dL)

Not performed



BUN (mg/dL)

Not performed



Creatinine (mg/dL)

Not performed



AST (U/L)

Not performed



ALT (U/L)

Not performed



Alkaline Phosphatase (ALP) (U/L)

Not performed



Total Bilirubin (mg/dL)

Not performed



Total protein (g/dL)

Not performed



Albumin (g/L)

Not performed



Lactate dehydrogenase (LDH) (U/L)

Not performed



Creatinine Kinase (CK) (U/L)

Not performed



Blood Gas

Not performed


ABG VBG

pH

Not performed



pCO2 (mmHg)

Not performed



pO2 (mmHg)

Not performed



HCO3 (mmol/L)

Not performed



Base Excess (mmol/L)

Not performed



If ABG, O2 Sat

Not performed



If ABG, FiO2

Not performed



Coagulation Panel

Not performed



PT (seconds)

Not performed



PTT (seconds)

Not performed



INR

Not performed



D dimer (mcg/mL)

Not performed



Fibrinogen

Not performed



Cardiac Biomarkers

Not performed



Troponin (ng/mL)

Not performed



BNP (pg/mL)

Not performed



Sepsis/Inflammatory Markers

Not performed



Lactate (mmol/L)

Not performed



Procalcitonin (ng/mL)

Not performed



CRP (mg/L)

Not performed



IL6 (pg/mL)

Not performed



Treatment Data

  1. Did the patient receive antibiotics within the first 48 hours of presentation? Yes No Unknown

  2. Did the patient receive antibiotics after the first 48 hours of presentation? Yes No Unknown

  3. Did the patient receive any of the following medications during treatment of this illness:

Medication


Route

Dosage

(units)

Frequency

Start Date (MM/DD/YYYY)

Last Date (MM/DD/YYYY)

Remdesivir

Y N Unk

PO IV IM

Other: ________





If yes, remdesivir use:

RCT Compassionate use Other trial

Chloroquine

Y N Unk

PO IV IM

Other: ________





Hydroxychloroquine

Y N Unk

PO IV IM

Other: ________





Lopinavir/ritonavir

Y N Unk

PO IV IM

Other: ________





Oseltamivir

Y N Unk

PO IV IM

Other: ________





Baloxavir marboxil

Y N Unk

PO IV IM

Other: ________





Ribavirin

Y N Unk

PO IV IM

Other: ________





Tocilizumab

Y N Unk

PO IV IM

Other: ________





Sarilumab

Y N Unk

PO IV IM

Other: ________





NSAIDs

Y N Unk






If yes, name: ___________________________

PO IV IM

Other: ________





Aspirin

Y N Unk

PO IV IM

Other: ________





Interferon Alpha

Y N Unk

PO IV IM

Other: ________





Interferon Beta

Y N Unk

PO IV IM

Other: ________





Azithromycin

Y N Unk

PO IV IM

Other: ________





Other antibiotics

Y N Unk






If yes, name: __________________________

PO IV IM

Other: ________





If yes, name: __________________________

PO IV IM

Other: ________





If yes, name: __________________________

PO IV IM

Other: ________





If yes, name: __________________________

PO IV IM

Other: ________





If yes, name: __________________________

PO IV IM

Other: ________





Systemic corticosteroids

Y N Unk

PO IV IM

Other: ________





Systemic Antifungals

Y N Unk






If yes, name: __________________________

PO IV IM

Other: ________





If yes, name: __________________________

PO IV IM

Other: ________





If yes, name: __________________________

PO IV IM

Other: ________





Inhaled Nitrous Oxide

Y N Unk

PO IV IM

Other: ________





Epoprostenol (Flolan)

Y N Unk

PO IV IM

Other: ________





Other relevant treatment for this illness:_________

Y N Unk

PO IV IM

Other: ________





Other relevant treatment for this illness:_________

Y N Unk

PO IV IM

Other: ________






  1. Was the patient in a clinical trial? Yes Not documented

If yes, what medication/intervention: _____________________________________________________________________________________

____________________________________________________________________________________________________________________


Imaging

  1. Was a chest x-ray taken? Yes No Unknown

  2. Were any of these chest x-rays abnormal? Yes No Unknown

Date of first abnormal chest x-ray: ______/_____/_______ (MM/DD/YYYY

  1. For first abnormal chest x-ray, please check all that apply: Report not available:

Air space density

Cannot rule out pneumonia

ARDS (acute respiratory distress syndrome)

Other

Air space opacity

Consolidation

Lung infiltrate

Pleural Effusion

Bronchopneumonia/pneumonia

Cavitation

Interstitial infiltrate

Empyema


Additional radiologist findings for first abnormal chest x-ray: __________________________________________________________________

____________________________________________________________________________________________________________________

  1. Was a chest CT/MRI taken? Yes No Unknown

  2. Were any of these chest CT/MRIs abnormal? Yes No Unknown

Date of first abnormal CT/MRI: ______/_____/_______ (MM/DD/YYYY)

  1. For first abnormal chest CT/MRI, please check all that apply: Report not available:

Air space density

Cavitation

Empyema

Englarged epiglottis

Air space opacity/opacification

Lung infiltrate

Pneumothorax

Tracheal narrowing

ARDS (acute respiratory distress syndrome)

Interstitial infiltrate

Pneumomediastinum

Ground glass opacities

Bronchopneumonia/pneumonia

Lobar infiltrate

Widened mediastinum

Cannot rule out pneumonia

Consolidation

Pleural effusion

Pulmonary Edema

Other

Additional radiologist findings for first abnormal chest CT/MRI: ________________________________________________________________

____________________________________________________________________________________________________________________


Infectious Disease Testing

  1. SARS-CoV-2 Testing (Please report further test results in comments)

Date of sample collection (MM/DD/YYYY)

Sample Type

Result

CT Value


NP OP Sputum

Other, specify: ___________________

Pos Neg Inconclusive

_________ not available


NP OP Sputum

Other, specify: ___________________

Pos Neg Inconclusive

_________ not available


NP OP Sputum

Other, specify: ___________________

Pos Neg Inconclusive

_________ not available


NP OP Sputum

Other, specify: ___________________

Pos Neg Inconclusive

_________ not available


NP OP Sputum

Other, specify: ___________________

Pos Neg Inconclusive

_________ not available


  1. Was patient tested for other viral respiratory pathogens during their illness? Yes (report results below) No Unknown


Positive

Negative

Not Tested/

Unknown

Collection Date

(MM/DD/YYY)

Specimen Type

Flu A

____/____/________


Flu A H1

____/____/________


Flu A H3/H3N2

____/____/________


Flu B

____/____/________


Flu (no type)



Respiratory syncytial virus/RSV

____/____/________


Adenovirus

____/____/________


Parainfluenza virus 1

____/____/________


Parainfluenza virus 2

____/____/________


Parainfluenza virus 3

____/____/________


Parainfluenza virus 4

____/____/________


Respiratory syncytial virus/RSV

____/____/________


Human metapneumovirus

____/____/________


Rhinovirus/enterovirus

____/____/________


Human coronavirus 229E

____/____/________


Human coronavirus HKU1

____/____/________


Human coronavirus NL63

____/____/________


Human coronavirus OC43

____/____/________


Other, specify: ______________________

____/____/________



  1. Were any bacterial culture tests performed during their illness? Yes No Unknown

If yes, was there a positive culture for a bacterial pathogen? Yes No Unknown

If yes, specify pathogen: __________________________________________________

If yes, specify date of culture (MM/DD/YYYY): ____________

If yes, site where pathogen identified: Blood Sputum Throat swab Bronchoalveolar lavage (BAL) Endotracheal aspirate Pleural fluid Cerebrospinal fluid (CSF) Other, specify: ___________________________

If more than one bacterial culture test was performed, please record in additional comments.

  1. Were any fungal culture tests performed during their illness? Yes No Unknown

If yes, was there a positive culture for a fungal pathogen? Yes No Unknown

If yes, specify pathogen: __________________________________________________

If yes, specify date of culture (MM/DD/YYYY): ____________

If yes, site where pathogen identified: Blood Sputum Bronchoalveolar lavage (BAL) Endotracheal aspirate Pleural fluid

Cerebrospinal fluid (CSF) Other, specify: ______________

If more than one fungal culture test was performed, please record in additional comments.


Outcome

  1. Did the patient die as a result of this illness?

Yes, Date: _____/_____/_____ (MM/DD/YYYY) No Unknown

Where did the death occur: Home Hospital ER Hospice Other, specify______________________________

Was autopsy performed? Yes No Unknown


(If the following information is not currently available, please send an update later using death certificate or death note in hospital record.)

Contribution of COVID-19 to death Underlying/primary Contributing/secondary No contribution to death Unknown

Primary Cause of death (death certificate/coroner) __________________________________________________________________________

ICD-10-CM Cause of Death (for multiple codes, separate by semi-colon): _________________________________________________________

____________________________________________________________________________________________________________________






Additional SOFA Tables

Date (MM/DD/YYYY)








PaO2 (mmHg)








FiO2 (0-1)








Is pt on MV?

Y N

Y N

Y N

Y N

Y N

Y N

Y N

PLT (10^3/uL)








GCS








Bilirubin (mg/dL)








MAP OR vasoactive agents required








Creatinine or UOP









Date (MM/DD/YYYY)








PaO2 (mmHg)








FiO2 (0-1)








Is pt on MV?

Y N

Y N

Y N

Y N

Y N

Y N

Y N

PLT (10^3/uL)








GCS








Bilirubin (mg/dL)








MAP OR vasoactive agents required








Creatinine or UOP









Additional Medications

Medication Name

Route

Frequency

Time period


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________

Prior to admission

During adminssion

At discharge


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________

Prior to admission

During adminssion

At discharge


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________

Prior to admission

During adminssion

At discharge


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________

Prior to admission

During adminssion

At discharge


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________

Prior to admission

During adminssion

At discharge


PO Injection Topical

Inhaled Other ______________

QD BID TID QOD

Unknown Other ________________

Prior to admission

During adminssion

At discharge





Any additional comments or notes?


Shape3



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPham, Huong T. (CDC/OID/NCHHSTP) (CTR)
File Modified0000-00-00
File Created2021-01-14

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