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

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

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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.