Download Medical History Form - Chart

Medical History Form - Chart
FORM CODE: MHC
VERSION:A 05/13/10
ID NUMBER:
Contact
Occasion
0
1
SEQ #
Administrative Information
/
0a. Completion Date:
Month
/
Day
0b. Staff ID:
Year
Instructions: This form is completed by chart abstraction. Conditions in the chart up to and including discharge from the index
event should be considered. Any condition that is in the chart after the day of discharge of the index event to the assessment date
(2-6 months later) is not to be coded. Affix the participant ID label above.
Part A. Charlson Comorbidity Questions
Does the medical chart indicate the presence or history of any of the following medical comorbidities at the
time of the index ACS event?
Condition
ICD-9 Code(s)
1
Myocardial infarction
410, 411
2
Congestive heart failure *
398, 402, 428
3
Peripheral vascular disease *
440-447
4
Dementia
290, 291, 294
5
Cerebrovascular disease
430-433, 435
6
Chronic pulmonary disease
491-493
7
Connective tissue disease
710, 714, 725
8
Ulcer disease
531-534
9
Mild liver disease
571, 573
10
Hemiplegia
342, 434, 436, 437
11
Moderate or severe renal disease
403, 404, 580-586
12
Diabetes
250
13
Any tumor
140-195
14
Leukemia
204-208
15
Lymphoma
200, 202, 203
16
Moderate or severe liver disease
070, 570, 572
17
Metastatic solid tumor
196-199
No
Yes
*Also part of GRACE
Medical History Form – Chart (MHC)
Page 1 of 6
ID #:
Part B. GRACE Comorbidity Questions
Medical History and Presentation characteristics
Does the medical chart indicate the presence or history of any of the following medical comorbidities
at the time of the index ACS event?
1. Hypertension
No
Yes
2. PCI
No
Yes
3. Pulse
4.
bpm
Blood pressure (SBP/DBP) at initial (index) presentation: a.
b.
Systolic (mmHg)
5. Killip class at initial (index) presentation:
I
.
6. Initial serum creatinine
II
III
Diastolic (mmHg)
IV
mg/dL
Initial elevated cardiac markers or enzymes
7. Troponin I or T performed?
No
Yes
If YES to 7, answer 7a-7c.
7a.
Instrument:
cTnI (cardiac troponin I)
cTnT (cardiac troponin T)
Other, specify: ________________
7b. Assay:
Abbott AxSYM ADV
Abbott Architect
Abbott i-STAT
Beckman Access Accu
Beckman Access hs-cTnI
bioMerieux Vidas Ultra
Innotrac Aio!
Inverness Bisite Triage
7c.
Mitsubishi PATHFAST
Nanosphere hs-cTnI
Ortho Vitros ECi ES
Radiometer AQT90
Response RAMP
Roche E170
Roche Elecsys 2010
Siemens Centaur Ultra
Siemens Dimension RxL
Siemens Immulite 2500
Siemens Stratus CS
Siemens VISTA
Singulex hs-cTnI
Tosoh AIA II
Other, specify:
_________________________
.
Troponin at initial hospital presentation:
ng/dL
8.
CK-MB > upper limit of hospital’s normal range, or if no CK-MB available, then total CPK > 2x upper
limit of the hospital’s normal range?
No
Yes
9.
Initial total cholesterol:
mg/dL
10. Initial triglycerides:
mg/dL
11. Initial LDL:
mg/dL
12. Initial HDL:
mg/dL
.
13. Initial hemoglobin A1c:
%
14. Cardiac arrest at initial (index) presentation?
Medical History Form – Chart (MHC)
No
Yes
Page 2 of 6
ID #:
Part C. Medical Comorbidity Questions
Does the medical chart indicate the presence or history of any of the following medical comorbidities at the time of
the index ACS event? NOTE: For questions 2-5, Unknown = No documentation of Positive or Negative History OR
Unclear documentation.
1. How many previous PCIs prior to the index cardiac event?
0
1
2
3 or more
2. Coronary Artery Bypass Surgery (CABG)
/
2a. If Yes, most recent date:
No
Yes
Unknown
/
Month
3. Dyslipidemia
No
Day
Yes
Year
Unknown
(As documented by (1) intake/discharge note, or (2) current use of hypolipidemic medication)
4.
AIDS
No
5.
Thyroid disease
Yes
Unknown (Note: not including those with asymptomatic HIV+)
No
5a. If Yes, type:
Yes
Unknown
Hyperthyroidism
Hypothyroidism
Part D. Index Acute Coronary Syndrome (ACS) Event
1.
Hospital Name: ________________________________________
2.
Hospital admission date:
/
/
Month
Day
Year
3. Transferred from another hospital?
No
Yes
If Yes:
3a. Hospital Name: ________________________________________
/
3b. Transfer date:
/
Month
4.
Day
/
Date of ACS diagnosis:
/
Month
5.
Year
Day
Year
/
Hospital discharge date:
Month
/
Day
Year
6.
Heart rate at discharge from index hospitalization:
7.
Blood pressure (SBP/DBP) at discharge from index hospitalization: a.
bpm
b.
Systolic (mmHg)
Medical History Form – Chart (MHC)
Diastolic (mmHg)
Page 3 of 6
ID #:
Part E. ECG Findings for Index ACS Event
1.
Admitting ECG available?
No
/
1a. Date of ECG:
/
Month
Day
Hour
Pre-discharge ECG available?
AM / PM
Minute
(circle one)
No
Yes
/
2a. Date of ECG:
Month
/
Day
:
2b. Time of ECG:
Hour
3. ECG changes?
Year
:
1b. Time of ECG:
2.
Yes
No
Year
AM / PM
Minute
(circle one)
Yes
If Yes, retain a copy of ECG on which diagnosis was made and a copy of subsequent ECG after “evolution” of the changes.
If Yes to #3 ECG changes, answer #4 and #5. If No, go to #6.
4. For the diagnostic ECG, indicate type(s) of ECG changes (check all that apply in 4a – 4d):
a. ST-segment elevation  0.1 mV elevation in 2 or more contiguous leads
(check all that apply):
Inferior leads (II, III, AVF)
Anterior leads (V1 to V4)
Lateral leads (I, aVL, V5 to V6)
True posterior (V1, V2) with tall R waves in these leads
b. Q waves greater  0.04 seconds in width and  0.1 mV in depth in at least 2 contiguous leads
(check all that apply):
Inferior leads (II, III, AVF)
Anterior leads (V1 to V4)
Lateral leads (I, aVL, V5 to V6)
True posterior (tall R waves in V1 V2)
c. ST-segment depression > 0.05 mV in 2 more contiguous leads (includes reciprocal changes)
d. T-wave inversion of at least 0.1 mV
5. For the ECG after evolution of the changes, indicate the pattern: ....
6. Paced rhythm? ................................
No
Yes
7. Atrial fibrillation or flutter? ................
No
Yes
8. Bundle branch block? ......................
No
Yes
8a. Type ......................................
RBBB
LBBB
8b. Timing ....................................
New
Old
Medical History Form – Chart (MHC)
Q wave
non-Q wave
Unknown
Page 4 of 6
ID #:
Part F. Procedures during hospitalization for Index ACS Event
1. Stress test?
No
Yes
If Yes, then answer the following:
/
1a. Date of test:
/
Month
Day
1b. Stress test type
Year
Exercise
Pharmacological
If Exercise, to target heart rate?
No
1c. Imaging type:
EKG only
1d. Ischemia Result
Positive
Nuclear
PET
Negative
1e. Fixed defect indicating an old MI:
1f.
Yes
Present
Echocardiogram
Equivocal
Absent
Other findings (e.g, hypotension, delayed hysteresis): __________________________
2. LV function assessed during hospitalization?
No
Yes
If Yes, then answer the following:
.
2a. Initial LVEF:
%
or check one:
2b.
Normal/Low normal
Mildly reduced
Mild-moderately reduced
3.
Moderately reduced
Moderate-severely reduced
Severely reduced
Diagnostic cardiac catheterization?
No
Yes
If Yes, then answer the following:
/
3a. Date:
/
Month
Day
Year
3b. Maximum stenosis (%):
LAD
4.
PCI performed?
LCx
No
RCx
LM
Yes
If Yes, then answer the following:
/
4a. Date:
/
Month
Day
Year
4b. Number of stents placed:
4c. Stent type:
Bare metal
Drug-eluting
4d. Complications of PCI?
No
Yes
If Yes, type: (check all that apply)
Bleeding
Vascular complication
Cardiac tamponade
5.
Arrhythmia
Stroke
Contrast reaction
Coronary Artery Bypass Surgery performed?
No
Acute renal failure
Yes
If Yes, then answer the following:
/
5a. Date:
Month
/
Day
Medical History Form – Chart (MHC)
Year
Page 5 of 6
ID #:
Part G. Medications at Discharge from Index ACS Event
NOTE: Record the medications prescribed to the patient at the time of discharge from the index ACS event
hospitalization. When entering the daily dose, use one of the boxes for the decimal point if necessary.
No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
ACE inhibitors ...............................
Angiotensin II receptor blockers .
Aspirin ............................................
Clopidogrel ....................................
Other antiplatelet agents .............
Anticoagulants (e.g., Warfarin) .......
Beta-blockers ................................
Calcium channel blockers ...........
Digitalis/Digoxin ............................
Other inotropic agent (not digitalis)
Diuretics .........................................
Statin lipid-lowering agents .........
Non-statin lipid-lowering agents .
Nitrates ...........................................
Vasodilators (not ACE inhibitors) .....
PO hypoglycemic antidiabetic ....
Insulin ...........................................
Antiarrhythmics .............................
Female hormone replacement
therapy ......................................
Thyroid replacement therapy ......
Antipsychotics ...............................
Other drug class ...........................
Other drug class ...........................
Other drug class ...........................
Other drug class ...........................
Medical History Form – Chart (MHC)
Yes Unknown
Name
Daily Dose
Units
______________
_____
______________
_____
______________
_____
______________
_____
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_____
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