Risk Factor - Chart Abstraction - CDC

……………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

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: ___________________________________________________

4. To where was the patient discharged?

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

Homeless Incarcerated Other ______________ Unknown

5. 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

6. 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

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

8. 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

9. 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.

10. 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): _____________

11. Lung exam normal: Yes No Unknown

If abnormal lung exam, describe: _______________________________________________________________________________________

12. Admitting Diagnoses

Admitting Diagnosis	ICD-10-CM Code
1.
2.
3.

13. 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: _____________________________________________________________________________________________________

14. 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

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

16. 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: ________________________________________________________________________________________________

17. 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

18. 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

19. 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

20. QTc from final available EKG: _________ seconds

21. Clinical Discharge Diagnoses and ICD10 Discharge Codes

Clinical Discharge Diagnoses	ICD-10-CM Code
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

22. 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

23. 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

24. 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

25. 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

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

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

28. 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: ________

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

If yes, what medication/intervention: _____________________________________________________________________________________

____________________________________________________________________________________________________________________

Imaging

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

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

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

32. 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: __________________________________________________________________

____________________________________________________________________________________________________________________

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

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

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

35. 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

36. 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

37. 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: ______________________				____/____/________

38. 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.

39. 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

40. 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?