10a Chart Review - Inpatient Hospitalization

Study ID: __ __ __ __ __ __ __ __ __ __
CEIRS Human Influenza Surveillance Study
Form 10A: Chart Review – Inpatient Hospitalization
Review the subject’s medical record for the day of enrollment and the subsequent 21 days for inpatient
hospitalizations.

How many times was the subject hospitalized and admitted in the past 21 days? ____ times
If none, skip to Form 11: 3-week Follow-up Other Doctors Visits
Inpatient Hospitalization Visit 1
Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Inpatient Hospitalization Visit 2
Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Inpatient Hospitalization Visit 3
Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Inpatient Hospitalization Visit 4
Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Inpatient Hospitalization Visit 5
Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Inpatient Hospitalization Visit 6
Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)

For each inpatient hospitalization, complete a separate Inpatient Hospitalization Chart Review
Form.

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Form 10A: Hospital chart review

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
Visit __ of __
Inpatient Hospitalization Chart Review Form
Instructions: For each inpatient hospitalization, complete an Inpatient Hospitalization Chart Review Form.
Begin with visit one and number sequentially. Do not including any information from ED visits.

Inpatient Hospitalization # ___
1. Date inpatient stay began: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
2. Date inpatient stay ended: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
3. Did the subject receive supplemental oxygen in the hospital?
No
3a. If yes, how much? ____________L/min
3b. What was the route?
Nasal cannula
Facemask/non-rebreather
BiPAP or CPAP

Yes

Unknown

Intubated

4. Was subject located in an intensive care unit?
No
If yes,
4a. Date ICU stay began: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
4b. Total number of days spent in ICU: __________

Yes

Unknown

5. Did Subject die in the hospital?
No
5a. If yes, Date of Death: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)

Yes

Unknown

6. Did the subject receive antibiotics in the hospital?
No
Yes
Unknown
6a. If yes, how many antibiotics were received? _______ antibiotics
6b. For each antibiotic received, specify the antibiotic name, the date the antibiotic was started, the
number of days it was taken for, and the condition for which it was prescribed.
6i. Antibiotic 1
Antibiotic 1 Name: _____________
Antibiotic 1 start date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Antibiotic 1 number of days taken: ___________ days
Antibiotic 1 indication:______________________
6ii. Antibiotic 2
Antibiotic 2 Name: _____________
Antibiotic 2 start date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Antibiotic 2 number of days taken: ___________ days
Antibiotic 2 indication:______________________
6iii. Antibiotic 3
Antibiotic 3 Name: _____________
Antibiotic 3 start date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Antibiotic 3 number of days taken: ___________ days
Antibiotic 3 indication:______________________
6iv. Antibiotic 4
Antibiotic 4 Name: _____________
Antibiotic 4 start date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Antibiotic 4 number of days taken: ___________ days
Antibiotic 4 indication:______________________

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Form 10A: Hospitalization Chart review

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
Visit __ of __
7. Did subject receive influenza testing in the hospital?
No
Yes
Unknown
7a. If yes, how many? _______ influenza tests
7b. For each influenza test, specify the following:
7i. Test 1
Test 1 Name: _____________
Test 1 Type: PCR DFA Culture Antigen Other: __________
Test 1 Result: Negative Positive Other
Test 1 Collection Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 1 Collection time (24-hour clock):__ __ : __ __ (hh:mm)
Test 1 Result Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 1 Result Time (24-hour clock): __ __ : __ __ (hh:mm)
Was influenza typing was performed?
No
Yes Unknown
If yes, please list influenza type: _______________
7ii. Test 2
Test 2 Name: _____________
Test 2 Type: PCR DFA Culture Antigen Other: __________
Test 2 Result:
Negative Positive Other
Test 2 Collection Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 2 Collection time (24-hour clock):__ __ : __ __ (hh:mm)
Test 2 Result Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 2 Result Time (24-hour clock): __ __ : __ __ (hh:mm)
Was influenza typing was performed?
No
Yes
Unknown
If yes, please list influenza type: _______________
7iii. Test 3
Test 3 Name: _____________
Test 3 Type: PCR DFA Culture Antigen Other: __________
Test 3 Result:
Negative Positive Other
Test 3 Collection Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 3 Collection time (24-hour clock):__ __ : __ __ (hh:mm)
Test 3 Result Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 3 Result Time (24-hour clock): __ __ : __ __ (hh:mm)
Was influenza typing was performed?
No
Yes
If yes, please list influenza type: _______________

Unknown

7iv. Test 4
Test 4 Name: _____________
Test 4 Type: PCR DFA Culture Antigen Other: __________
Test 4 Result:
Negative Positive Other
Test 4 Collection Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 4 Collection time (24-hour clock):__ __ : __ __ (hh:mm)
Test 4 Result Date: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Test 4 Result Time (24-hour clock): __ __ : __ __ (hh:mm)
Was influenza typing was performed?
No
Yes
If yes, please list influenza type: _______________

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Form 10A: Hospitalization Chart review

Unknown

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
Visit __ of __
8. Did subject receive influenza antiviral in the hospital?
No
Yes Unknown
8a. If yes, how many antivirals were received? _______ influenza antivirals
8b. For each influenza antivirals received, specify the antiviral name, route of administration, and date the
influenza antiviral was given.
(Key: PO = by mouth; IN = intranasal; IV = intravenous)
8i. Influenza antiviral 1
Influenza Antiviral 1 Name: _____________
Influenza Antiviral 1 Route:
PO IN
IV
Influenza Antiviral 1 Date administered: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Influenza Antiviral 1 Time administered (24-hour clock): __ __ : __ __ (hh:mm)
8ii. Influenza antiviral 2
Influenza Antiviral 2 Name: _____________
Influenza Antiviral 2 Route:
PO IN
IV
Influenza Antiviral 2 Date administered: __ __/ __ __ / __ __ __ __ (mm/dd/yyyy)
Influenza Antiviral 2 Time administered (24-hour clock): __ __ : __ __ (hh:mm)
9. Did the subject have a final diagnosis of
9a. Influenza?
9b. Viral Syndrome or Infection?
9c. Pneumonia?
9d. Myocardial Infarction?
9e. Stroke?

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

Unknown
Unknown
Unknown
Unknown
Unknown

10. How many final inpatient hospitalization diagnoses did the subject have?
1
2
3
more than three
List the ICD-9 codes for up to the first few final inpatient hospitalization diagnoses, up to the first three:
(Do not use any E or V codes)
10a. Final Inpatient Diagnosis Code 1: ___________________
10b. Final Inpatient Diagnosis Code 2: ___________________
10c. Final Inpatient Diagnosis Code 3: ___________________

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Form 10A: Hospitalization Chart review

Version 2.0
01/05/2015