Form 0920-0212 Validation of Enhanced Algorithms to Identify Opioid Use

National Hospital Care Survey

Abstraction Form_03_13_2020_FINAL_OMB

National Hospital Care Survey (Abstraction Form)

OMB: 0920-0212

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Attachment A – Abstraction Form


Validation of Enhanced Algorithms to Identify Opioid Use and Co-Occurring Disorders in National Hospital Care Survey (NHCS)

Abstraction Form


OMB No. 0920-0212; Expiration date 03/31/2022

Notice of Estimated Burden – CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0212).


Assurance of Confidentiality – We take your privacy very seriously.  All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes.  NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529)).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. 



Use the below prepopulated information to locate the full medical record for the selected encounter in the hospital’s EHR system. Verify that the correct medical record was selected before proceeding with abstraction.

Hospital_ID

XXXXXXXXXX


Encounter_ID

XXXXXXXXXX


Medical Record Number (MRN)

XXXXXXXXXXXXXXXXXXX


Setting

  • Emergency Department (ED)

  • Inpatient (IP)


Encounter Start Date

DD MON YYYY


Encounter End Date

DD MON YYYY


Patient Date of Birth

DD MON YYYY


Patient Name

LAST, FIRST MI


Patient Sex

XXXXXXXXXXXX

Patient Address


XXXXXXXXXXXX

Answer all the following questions using only information found in the medical record for the above referenced encounter. Exclude encounters that occurred before or after the referenced encounter.


Question 1.

Response

Did the patient have at least one diagnosis related to past or present opioid use? (Select one)



  • Yes

  • No (Skip to Question 2) 


Question 1a.

Response

Which diagnosis related to past or present opioid use did the patient have? (Select all that apply)


NOTE: Includes a diagnosis code or a diagnostic phrase, such as a label or description for a diagnosis code.


Opioid related disorders

  • Opioid abuse

  • Opioid dependence

  • Opioid use


Poisoning by:

  • Opium

  • Heroin

  • Other opioids

  • Methadone

  • Other synthetic narcotics

  • Unspecified narcotics

  • Other narcotics


Adverse Effect of:

  • Opium

  • Other opioids

  • Methadone

  • Other synthetic narcotics

  • Unspecified narcotics

  • Other narcotics

Underdosing of:

  • Opium

  • Other opioids

  • Methadone

  • Other synthetic narcotics

  • Unspecified narcotics

  • Other narcotics


Miscellaneous Opioid Use:

  • Long term current use of opiate analgesic

  • Finding of opiate in blood

  • Newborn affected by maternal use of opiates

  • Neonatal withdrawal symptoms from maternal use of drugs of addiction

  • Other (please specify) ___________




















Question 1b.

Response

Where did you find evidence of a diagnosis related to past or present opioid use? (Select all that apply)



  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 2.

Response

Did the patient have at least one written indication of past or present opioid use stated by the patient or provider other than the diagnosis(es) indicated in question 1? (Select one)



  • Yes

  • No (Skip to Question 3) 


Question 2a.

Response

Describe the written indication of past or present opioid use, copy verbatim from chart when possible. (Enter up to three)


NOTE: Excludes diagnosis(es) indicated in Question 1. Include information regarding the intent of the opioid use if documented in the record (e.g., unintentional/accidental, suicide attempt & intentional self-harm, assault).


  • Written indication 1 ____________________________

  • Written indication 2 ____________________________

  • Written indication 3 ____________________________



Question 2b.

Response

Where did you find evidence of the written indication of past or present opioid use?

(Select all that apply)

  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe):

____________________





Question 3.

Response

Was any drug testing performed during the encounter? (Select one)

  • Yes

  • No (Skip to Question 4) 


Question 3a.

Response

Were any drug tests positive? (Select one)

  • Yes

  • No, negative for all tested substance (Skip to 3c)

  • Don’t know/No results provided (Skip to 4)


Question 3b.

Response

Which substance(s) had positive test results? (Select all that apply)

  • Amphetamines

  • Barbiturates

  • Benzodiazepines

  • Buprenorphine/ Norbuprenorphine

  • Cannabis/Marijuana (THC)

  • Cocaine

  • Codeine

  • Ethanol/Alcohol

  • Fentanyl/Fentanyl Analogs

  • Heroin (6-AM & 6-MAM)

  • Hydrocodone

  • Hydromorphone

  • Levorphanol


  • Methadone

  • Methamphetamine

  • Mitragynine (Kratom)

  • Morphine

  • Naloxone

  • Naltrexone

  • Opiates

  • Oxycodone

  • Oxymorphone

  • Phencyclidine (PCP)

  • Tramadol

  • Tricyclic antidepressants (TCA)

  • Other (please describe)

__________________________



Question 3c.

Response

Where did you find evidence of drug testing? (Select all that apply)

  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): ___________________


Question 4.

Response

Was at least one prescription opioid administered and/or prescribed to the patient during the encounter or listed on Past or Current Medication Lists? (Select one)


  • Yes

  • No (Skip to Question 5) 





Question 4a.

Response

Which prescription opioid(s) was administered and/or prescribed to the patient? (Select all that apply)

  • Buprenorphine

  • Codeine

  • Fentanyl

  • Hydrocodone

  • Hydromorphone

  • Levorphanol

  • Meperidine

  • Methadone

  • Morphine

  • Oxycodone

  • Oxymorphone

  • Tramadol

  • Other (please describe):

____________________





Response


Question 4b.

Opioid

Prior to Encounter

Given during Encounter

Prescribed upon

Discharge

When was the prescription opioid(s) administered and/or prescribed to the patient?

(Select all that apply)


NOTE: Opioids administered prior to encounter include those listed on Past and Current Medication Lists



Buprenorphine

Codeine

Fentanyl

Hydrocodone

Hydromorphone

Methadone

Morphine

Oxycodone

Oxymorphone

Tramadol

Other (please describe):

____________________





Question 4c.

Response

Where did you find evidence of opioid(s) administered and/or prescribed to the patient? (Select all that apply)

  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 5.

Response

Was naloxone (Narcan) administered to the patient either during the encounter or shortly before arrival? (Select one)

  • Yes

  • No (Skip to Question 6) 

  • Unknown (Skip to Question 6)






Question 5a.

Response

Who administered naloxone (Narcan)? (Select all that apply)

  • EMS

  • Firefighter

  • Law enforcement

  • Hospital provider

  • Family/friend/bystander

  • Other

  • Unknown


Question 5b.

Response

How many doses of naloxone (Narcan) were administered? (Select one)

  • Single

  • Multiple

  • Unknown


Question 5c.

Response

Did naloxone (Narcan) administration result in a positive response (e.g., increased respiration and/or increased alertness)? (Select one)

  • Yes

  • No

  • Unknown


Question 5d.

Response

Where did you find evidence of naloxone (Narcan) administration?

(Select all that apply)

  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 6.

Response

Did the patient have at least one diagnosis related to a past or present substance use disorder? (Select one)


NOTE: Includes a diagnosis code or a diagnostic phrase, such as a label or description for a diagnosis code.


  • Yes

  • No (Skip to Question 7) 










Question 6a.

Response

Which diagnosis related to a past or present substance use disorder did the patient have? (Select all that apply)


NOTE: Includes a diagnosis code or a diagnostic phrase, such as a label or description for a diagnosis code.



  • Alcohol related disorders

  • Opioid related disorders

  • Cannabis related disorders

  • Sedative, hypnotic or anxiolytic related disorders

  • Cocaine related disorders

  • Other stimulant related disorders

  • Hallucinogen related disorders

  • Nicotine dependence

  • Inhalant related disorders

  • Other psychoactive substance related disorders

  • Other (please describe): _____________________



Question 6b.

Response

Where did you find evidence of a diagnosis related to past or present substance use disorder?

(Select all that apply)



  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 7.

Response

Was there at least one written indication of past or present substance use disorder stated by the patient or provider other than the diagnosis(es) indicated in question 6? (Select one)



  • Yes

  • No (Skip to Question 8) 


Question 7a.

Response

Describe the written indication of a past or present substance use disorder, copy verbatim from chart when possible. (Enter up to three)


NOTE: Excludes diagnosis(es) indicated in Question 6.



  • Written indication 1 ____________________________

  • Written indication 2 ____________________________

  • Written indication 3 ____________________________










Question 7b.

Response

Where did you find evidence of a written indication of a past or present substance use disorder?

(Select all that apply)


NOTE: Excludes diagnosis(es) indicated in Question 6.


  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 8.

Response

Did the patient have at least one diagnosis related to a past or present anxiety disorder? (Select one)


NOTE: Includes a diagnosis code or a diagnostic phrase, such as a label or description for a diagnosis code.

  • Yes

  • No (Skip to Question 9) 


Question 8a.

Response

Which diagnosis related to a past or present anxiety disorder did the patient have? (Select all that apply)


NOTE: Includes a diagnosis code or a diagnostic phrase, such as a label or description for a diagnosis code.



  • Social phobias

  • Panic disorder

  • Generalized anxiety disorder

  • Other anxiety disorders

  • Obsessive-compulsive disorder

  • Acute stress reaction

  • Post-traumatic stress disorder (PTSD)

  • Other (please describe):

_____________________













Question 8b.

Response

Where did you find evidence of a diagnosis related to a past or present anxiety disorder?

(Select all that apply)



  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________



Question 9.

Response

Was there at least one written indication of past or present anxiety disorder stated by the patient or provider other than the diagnosis indicated in question 8? (Select one)



  • Yes

  • No (Skip to Question 10) 


Question 9a.

Response

Describe the written indication of a past or present anxiety disorder, copy verbatim from chart when possible. (Enter up to three)


NOTE: Excludes diagnosis(es) indicated in Question 8.



  • Written indication 1 ____________________________

  • Written indication 2 ____________________________

  • Written indication 3 ____________________________


Question 9b.

Response

Where did you find evidence of a written indication of a past or present anxiety disorder?

(Select all that apply)


NOTE: Excludes diagnosis(es) indicated in Question 8.


  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________





Question 10.

Response

Was there at least one diagnosis related to a past or present depressive disorder? (Select one)


NOTE: Includes a diagnosis code or a diagnostic phrase, such as a label or description for a diagnosis code.


  • Yes

  • No (Skip to Question 11) 


Question 10a.

Response

Which diagnosis related to a past or present depressive disorder did the patient have? (Select all that apply)


NOTE: Includes a diagnosis code or a diagnostic phrase, such as a label or description for a diagnosis code.


  • Major depressive disorder, single episode

  • Major depressive disorder, recurrent

  • Personal history of self-harm

  • Suicidal ideations

  • Suicide attempt

  • Other (please describe):

_____________________



Question 10b.

Response

Where did you find evidence of a diagnosis related to a past or present depressive disorder?

(Select all that apply)



  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 11.

Response

Was there at least one written indication of past or present depressive disorder as stated by the patient or provider other than the diagnosis indicated in question 10? (Select one)



  • Yes

  • No (Skip to Question 12) 











Question 11a.

Response

Describe the written indication of a past or present depressive disorder, copy verbatim from chart when possible. (Enter up to three)


NOTE: Excludes diagnosis(es) indicated in Question 10. For written indications of self-harm thoughts and behaviors, include whether they were related to a comorbidity of schizophrenia if documented in the record.

  • Written indication 1 ____________________________

  • Written indication 2 ____________________________

  • Written indication 3 ____________________________



Question 11b.

Response

Where did you find evidence of a written indication of a past or present depressive disorder?

(Select all that apply)


NOTE: Excludes diagnosis(es) indicated in Question 10.

  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 12.

Response

Was any treatment initiated for the patient’s substance use disorder (SUD), anxiety disorder and/or depressive disorder during this encounter? (Select one)

  • Yes

  • No (Skip to Question 13)

  • N/A, patient does not have a substance use disorder, anxiety disorder or depressive disorder (Skip to 13)


Question 12a.

Response

What treatment was initiated during this encounter? (Select all that apply)

  • Buprenorphine, Methadone or Naltrexone

  • Admitted to a chemical dependency/detoxification unit at the hospital

  • Psychotropic medication

  • Admitted to a psychiatric inpatient unit at this hospital

  • Brief intervention counseling

  • Transferred/referred to another facility

  • Other (please describe):

________________________________










Question 12b.

Response

Where did you find evidence of treatment initiated during this encounter?

(Select all that apply)

  • Allergies

  • Assessment & Plan

  • Chief Complaint

  • Diagnoses

  • Discharge Summary

  • EMS Report

  • Family History

  • History of Present Illness (HPI)

  • Lab/Toxicology

  • Medication List

  • Nurses Notes

  • Past Medical History

  • Physical Examination

  • Problem List

  • Progress Note

  • Reason for Visit

  • Review of Systems

  • Services

  • Social History

  • Other (please describe): __________________


Question 13.

Response

Abstractor Notes


Use this space to describe any issues with abstracting information for this encounter or any other pertinent information.






File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWilliams, Bryan (CDC/DDPHSS/NCHS/DHCS) (CTR)
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File Created2021-01-13

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