AppxG MedChartAbstrct Form SAMPLE

Appendix H: Medical Chart Abstraction Form SAMPLE

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 _______________

U 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