AppxG MedChartAbstrct Form SAMPLE

AppxG MedChartAbstrct Form SAMPLE.docx

[ATSDR] Assessment of Chemical Exposures (ACE) Investigations

AppxG MedChartAbstrct Form SAMPLE

OMB: 0923-0051

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Appendix H: Medical Chart Abstraction Form SAMPLE

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Form Approved

OMB No. 0923-0051

Exp XX/XX.XXXX




Medical Chart Abstraction Form







Reviewer Name: _____________________Review Date: ___ / ___ / ____ Start Time __:___ □am □pm

Facility (list names of facilities here for reviewer to pick one)

□ □

□ □

□ □



Patient Name ____________________, _____________________ ___

Last First M.I.


Patient Address: Street: ___________________________ City: ___________________ State: _____ Zip: ____________


Telephone (Home) ______________(Cell) ______________(Work) ______________(Other) ______________



Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data 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 Clearance Officer, 1600 Clifton Road NE, MS H21–8, Atlanta, Georgia 30329 ATTN: PRA (0923-0051)


Patient Demographics

DOB: ____ / ____ / _______ Age: ______ years


MM DD YYYY

Sex (biological): □ Male □ Female □ other/unknown


Race and/or ethnicity? (Select all that apply)

  • American Indian or Alaska Native (For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)

  • Asian (For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)

  • Black or African American (For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)


  • Hispanic or Latino (For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)

  • Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)

  • Native Hawaiian or Pacific Islander (For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)

  • White (For example, English, German, Irish, Italian, Polish, Scottish, etc.)


Occupation: _______________________□unknown

Insurance:

□ Private □ Government/Military

□ Medicare □ Medicaid

□ No coverage □ Other: __________________


Visit Information

Date of Visit: ____ / ____ / ______ Time of arrival: ____:____ □ am □ pm

MM DD YYYY

Chief Complaint ___________________________________________________________________________________


Description of what happened________________________________________________________________________


Location when became injured/ill home work commute □ school unknown other______________________


Mode of arrival: □ Helicopter □ Ambulance □POV □ Public transportation □ On foot □ Other: _________________o


If applicable: Did vehicle need to be decontaminated? □Yes □No

Initial Vital Signs: Height: _________ □ cm □ in Weight: ________ □ kg □ lb

Temp (°): _______F or C Heart Rate: _______ Respiratory Rate: _______ BP (mmHg): ______ / _______


Decontamination

Was the patient decontaminated? □ Yes □ No □ N/A How was the patient decontaminated? (check all that apply)

If yes, where was the patient decontaminated? □ Clothing removed

□ In the field/At site □ Water

□ At hospital □ Soap and water

□ Both □ N/A

□ N/A □ Other: __________________________________

□ Other: ___________________________

Medical History (check all that apply)

□ Anxiety Medication 1: _____________________________________________

□ Asthma Medication 2: _____________________________________________

□ Breastfeeding Medication 3: _____________________________________________

□ Congestive heart failure Medication 4: _____________________________________________

□ COPD □ Pregnant estimated due date __/__/__

□ Depression □ Sleep difficulties

□ Diabetes □ Tobacco use

□ GERD (Reflux) □ Drug/alcohol abuse___________________

□ Hypertension □ Other ______________________________

□ Malignancy □ Other ______________________________

□ Myocardial infarction □ Other ______________________________

□ Post-traumatic stress disorder □ Other ______________________________

Signs and Symptoms

Check box if sign or symptom is present in the medical record (for this encounter). If date of onset is different from date of presentation, indicate in date column.

Sign/Symptom Date

General

□ Chills ___ / ___ / ____

□ Fever (>100.4 °F) ___ / ___ / ____

□ Fatigue/Malaise ___ / ___ / ____

□ Hypothermia (<95.0 °F) ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Eye

□ Corneal abrasion ___ / ___ / ____

□ Increased tearing ___ / ___ / ____

□ Irritation/Pain ___ / ___ / ____

□ Itching/Pruritis ___ / ___ / ____

□ Miosis ___ / ___ / ____

□ Mydriasis ___ / ___ / ____

□ Visual changes ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Cardiovascular

□ Bradycardia ___ / ___ / ____

□ Cardiac arrest ___ / ___ / ____

□ Chest pain __ / ___ / ____

□ Hypertension ___ / ___ / ____

□ Hypotension ___ / ___ / ____

□ Palpitations ___ / ___ / ____

□ Tachycardia ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Respiratory

□ Chest tightness ___ / ___ / ____

□ Cough ___ / ___ / ____

□ Cyanosis ___ / ___ / ____

□ Dyspnea/ SOB ___ / ___ / ____

□ Hyperventilation/Tachypnea ___ / ___ / ____

□ Lower airway pain/irritation ___ / ___ / ____

□ Nose bleed ___ / ___ / ____

□ Pleuritic chest pain ___ / ___ / ____

□ Phlegm/Congestion ___ / ___ / ____

□ Runny nose ___ / ___ / ____

□ Stridor ___ / ___ / ____

□ Upper airway pain/irritation ___ / ___ / ____

□ Wheezing ___ / ___ / ____ □ Other: __________________ ___ / ___ / ____


Sign/Symptom Date

Gastrointestinal

□ Abdominal pain ___ / ___ / ____

□ Anorexia ___ / ___ / ____

□ Constipation ___ / ___ / ____

□ Diarrhea ___ / ___ / ____

□ Nausea ___ / ___ / ____

□ Vomiting ___ / ___ / ____


Nervous System

□ Ataxia ___ / ___ / ____

□ Confusion ___ / ___ / ____

□ Dizzy/Vertigo ___ / ___ / ____

□ Fainting ___ / ___ / ____

□ Fasciculations ___ / ___ / ____

□ Headache ___ / ___ / ____

□ Hyperactive/anxiety/irritable ___ / ___ / ____

□ Lightheaded ___ / ___ / ____

□ Loss of balance ___ / ___ / ____

□ Memory loss ___ / ___ / ____

□ Muscle pain ___ / ___ / ____

□ Muscle rigidity ___ / ___ / ____

□ Muscle weakness ___ / ___ / ____

□ Paralysis ___ / ___ / ____

□ Peripheral neuropathy ___ / ___ / ____

□ Salivation ___ / ___ / ____

□ Tingling/Numbness ___ / ___ / ____

□ Other: __________________ ___ / ___ / ____


Skin

□ Burns ___ / ___ / ____

□ Edema/Swelling ___ / ___ / ____

□ Erythema/Redness/Flushing ___ / ___ / ____

□ Hives/Welts ___ / ___ / ____

□ Irritation/Pain ___ / ___ / ____

□ Itching/Pruritis ___ / ___ / ____

□ Rash ___ / ___ / ____

□ Other: __________________ ___ / ___ / ___



Disability

□ Vision difficulty (e.g. blind or having serious difficulty seeing) ___ / ___ / ____

□ Hearing difficulty (e.g. deaf or having serious difficulty hearing) ___ / ___ / ____

□ Mobility difficulty (e.g. serious difficulty walking or climbing stairs ___ / ___ / ____

□ Cognition difficulty (e.g. serious difficulty remembering or making decisions) ___ / ___ / ____

□ Self-care difficulty (e.g. serious difficulty bathing or dressing) ___ / ___ / ____

□ Independent living difficulty (e.g. serious difficulty doing errands along) ___ / ___ / ____

□ Communication (e.g. serious difficulty understanding or being understood) ___ / ___ / ____

□ Intellectual/developmental ___ / ___ / ____

□ Other: __________________­­­­­­­­­­__ ___ / ___ / ___

Imaging

Date

Type of Imaging

Location

Contrast

Acute Findings

Description of Acute Findings

__/__/____

□ X-ray

□ CT

□ MRI

□ Ultrasound

□ Other: _____



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ CT

□ MRI

□ Ultrasound

□ Other: _____



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ CT

□ MRI

□ Ultrasound

□ Other: _____



□ Y

□ N


□ Y

□ N


___ / ___ / ____


□ X-ray

□ CT

□ MRI

□ Ultrasound

□ Other: _____



□ Y

□ N


□ Y

□ N



EKG

Date

Findings

Description of EKG Findings

___ / ___ / ____


□ WNL

□ Abnl, consistent

□ Abnl, new


___ / ___ / ____


□ WNL

□ Abnl, consistent

□ Abnl, new




WNL- within normal limits

Abnl, consistent- Abnormal finding, consistent with medical history or previous disease

Abnl, new- Abnormal finding, may indicate the presence of new disease



e key below for check box explanations)

(Only record actual value if it is initially abnormal or becomes abnormal. Do not record normal values.)

Lab


Repeat Lab Values (if necessary)

Na


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

K


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Cl


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

HCO3-


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

BUN


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Cr


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Glu


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Ca2+


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

AST


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

ALT


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Total Bili


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Alk Phos


_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Hgb

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm

Hct

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm

WBC

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm

Plts

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm

Other:

_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Other:

_______

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other

Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


UShape3 rinaly sis

Lab

Date: ___ / ___ / ____

Repeat Lab Values (if necessary)

pH

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Specific Gravity

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Protein

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Glucose

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Ketones

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

WBC

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

RBC

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________

Bilirubin

□ WNL

□ Abnl, CI

□ Abnl, C Dz

□ Abnl, exposure

□ Abnl, other


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________


WNL- Within normal limits

Abnl, CI- Abnormal, Clinically insignificant (To be determined with NCEH Toxicologists)

Abnl, C Dz- Abnormal finding, consistent with documented chronic disease

Abnl, exposure- Abnormal finding, potentially associated with the exposure

Abnl, other- Clinically significant abnormality, related to other disease process



Pulmonary Function Tests


Predicted Value

Measured Value

% Predicted

Forced Vital Capacity




Forced Expiratory Volume (FEV1)




FEV1/FVC




Peak Expiratory Flow Rate




Forced Inspiratory Vital Capacity




Forced Expiratory Flow





Blood Gas (ABG) Flow Sheet

Date

Date

Date

Date

Time

Time

Time

Time

□Arterial □Venous

□Arterial □Venous

□Arterial □Venous

□Arterial □Venous

pH

pH

pH

pH

pO2

pO2

pO2

pO2

pCO2

pCO2

pCO2

pCO2

HCO3-

HCO3-

HCO3-

HCO3-

O2 sat

O2 sat

O2 sat

O2 sat

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.

Supplemental O2

Y □ N □ N/A

If Yes,

□ NC/FM

□ NRB

□ CPAP

□ Mechanical Vent.


Medications (new medications that were initiated or prescribed during this visit/admission)

Name

Indication

Given during this visit?

Continued after discharge?
























Consults


□ Cardiology: _______________________________________________________________________________________

__________________________________________________________________________________________________

□ Dermatology: _____________________________________________________________________________________

__________________________________________________________________________________________________

□ ENT: ____________________________________________________________________________________________

__________________________________________________________________________________________________

□ Gastroenterology: _______________________________________________________________________________________

__________________________________________________________________________________________________□ Ob/Gyn: _______________________________________________________________________________________

__________________________________________________________________________________________________□ Ophthalmology: ___________________________________________________________________________________

__________________________________________________________________________________________________

□ Pulmonary: _______________________________________________________________________________________

__________________________________________________________________________________________________

□ Poison Control: ___________________________________________________________________________________

__________________________________________________________________________________________________

□ Psychiatry/Mental health: _______________________________________________________________________________________

__________________________________________________________________________________________________

□ Social Work: ______________________________________________________________________________________

__________________________________________________________________________________________________

□ Surgery: _________________________________________________________________________________________

__________________________________________________________________________________________________

□ Other: ___________________________________________________________________________________________

__________________________________________________________________________________________________




Outcomes


Primary Diagnosis: __________________________________________________________________________________



Secondary Diagnosis: ________________________________________________________________________________



ICD-10 Codes

1. ___________________ 2. _________________ 3. ____________________


4. ___________________ 5. _________________ 6. ____________________


Did any staff or other patients get ill from this patient (secondary exposure)? □ Yes □No □Unknown


If yes, explain what happened________________________________________________________



Discharge


Was the patient admitted? □ Y □ N if yes, Where to □ICU #days __□ floor #days________□ observation # days____

Discharge information: Date: ___ / ___ /____ Time: ____: _____ □ am □ pm □ □LWBS- Left without being seen



□ Died: ___ / ___ /____ Cause of death: _________________________________________________________________

□ Other: ___________________________________

Discharge instructions_______________________________________________________________________________


End of chart review Date___/___/___ Time __:___ □ am □ pm

Secondary reviewer Name_____________________________ Date___/___/___ Time __:___ □ am □ pm



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