Medical Chart Abstraction Form

Medical Chart Abstraction Form

Reviewer Name: ______Date of Review: ___ / ___ / ____ Data entered: ___ / ___ / ____

Facility: ______ID: ______

Patient Name: ______

Address: Street: ______City: ______State: _____ Zip: ______Telephone (Home) ______(Cell)______(Work)______(Other)______

Patient Demographics

DOB: ____ / ____ / ______Sex: □ Male □ Female □ N/AEthnicity: □ Hispanic □ Not Hispanic □ N/A

MM DD YYYY

Insurance:Race:(check all that apply)

□ Private□ Medicare/Medicaid/Government program □ American Indian/ Alaskan Native □ Asian □ Black

□ None□ N/A□ Other: ______□ Native Hawaiian/ Pacific Islander □ White □ N/A

□ Other (specify): ______

Visit Information

Date of Visit: ____ / ____ / ______Time of arrival: ____:____ □ am □ pm

MM DD YYYY

Chief Complaint: ______

Mode of arrival:Was the patient admitted? □ Y □ N

□ HelicopterIf yes,

□ Ambulance□ Admitted to monitored ward or ICU

□POV# Days: ______

□ Public transportation (bus, taxi, etc.)□ Admitted to unmonitored ward

□On foot# Days: ______

□ Other: ______

Initial Vital Signs: Height: ______□ cm □ in Weight: ______□ kg □ lb

Temp (°F): ______Heart Rate: ______Respiratory Rate: ______BP (mmHg): ______/ ______

O2 sat: ______Supplemental O2? □ Y □ N □ N/A If yes, delivery method: ______

Medical History(check all that apply)

□ Asthma□ Congestive heart failureMedications:

□COPD□ Breastfeeding______

□ Depression□ Pregnant

□ Diabetes□ Tobacco use______

□ GERD (Reflux)□ Other: ______

□Hypertension______

□Malignancy______

□Myocardial infarction ______

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: ______

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/SymptomDate

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/SymptomDate

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: ______/ ___ / ____

Imaging

Date / Type of Imaging / Location / Contrast / Acute Findings / Description of Acute Findings
___ / ___ / ____ / □ X-ray
□ CT
□ MRI
□ Other:
______/ □ Y
□ N / □ Y
□ N
___ / ___ / ____ / □ X-ray
□ CT
□ MRI
□ Other:
______/ □ Y
□ N / □ Y
□ N
___ / ___ / ____ / □ X-ray
□ CT
□ MRI
□ Other:
______/ □ Y
□ N / □ Y
□ N
___ / ___ / ____ / □ X-ray
□ CT
□ MRI
□ 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

Lab Values (See 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 ______
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 ______
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 ______
AlkPhos
______/ □ 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 ______
Other:
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______

Urinalysis

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

Arterial Blood Gas (ABG) Flow Sheet

Date / Date / Date / Date
Time / Time / Time / Time
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: ______

______

□ Ophthalmology: ______

______

□ Pulmonary: ______

______

□ Poison Control: ______

______

□ Psychiatry: ______

______

□ Social Work: ______

______

□ Surgery: ______

______

□ Other: ______

______

Outcomes

Primary Diagnosis: ______

Secondary Diagnosis: ______

ICD-9 Codes

1. ______2. ______3. ______

4. ______5. ______6. ______

Discharge

□ LWBS□ Discharged from ED: Date: ___ / ___ /____ Time: ____: _____ □ am □ pm

□ Admitted: ___ / ___ /____ Discharge information: Date: ___ / ___ /____ Time: ____: _____ □ am □ pm

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

□ Other: ______

LWBS- Left without being seen