Chart Abstraction Tool

Patient Code: ___________

Dialysis–related Arrest Chart Abstraction Tool

Clinic Name:	___________________
Patient Name:	___________________
Patient Code:	__ __ __ __ __ __ __
Episode Date:	__ __ / __ __ / __ __	__ __ : __ __ AM PM

Demographics
Patient Code:	__ __ __ __ __ __ Abstractor: __________________
Sex:	Male	Female AGE: _______ years
Race:	White		Black/AA	Asian	American Indian/ Alaskan Native	Native Hawaiian/ Pacific Islander
Ethnicity:	Hispanic	Non-hispanic

Past Medical History
	Yes	No	Unknown	Additional Details
Stroke/Cerebrovascular Disease
CAD/Ischemic Heart Disease
Heart Failure				EF:____ Other:
Arrhythmia
Recent vascularization/Catheterization
Implantable Cardiodefbrillator
Diabetes				A1c (if known):___ Insulin-dep? Yes No Unk
Cancer
Autoimmune Disease
Seizure
Syncope
Any known drug allergies?				Details:
Any history of anaphylaxis?				Details:
List any other relevant medical conditions and details: __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________

Was the patient taking any of the following medications?
Class	Yes/No	Name	Dose (mg)	Route		Frequency		Was medicine taken the day of the event?
Beta-blocker	Yes No Unknown	__________	_____	PO	Other _________	Daily	BID	Yes	No
						TID	4x/day	Time taken: Unknown __ __ : __ __ AM PM
						Other __________
ACEI	Yes No Unknown	__________	_____	PO	Other _________	Daily	BID	Yes	No
						TID	4x/day	Time taken: Unknown __ __ : __ __ AM PM
						Other __________
ARB	Yes No Unknown	__________	_____	PO	Other _________	Daily	BID	Yes	No
						TID	4x/day	Time taken: Unknown __ __ : __ __ AM PM
						Other __________
CCB	Yes No Unknown	__________	_____	PO	Other _________	Daily	BID	Yes	No
						TID	4x/day	Time taken: Unknown __ __ : __ __ AM PM
						Other __________
Diuretic	Yes No Unknown	__________	_____	PO	Other _________	Daily	BID	Yes	No
						TID	4x/day	Time taken: Unknown __ __ : __ __ AM PM
						Other __________

List any other home medications:
Name	Dose	Route	Frequency	Taken on day of event?
________________	____ mg	PO Other ______	Daily BID TID 4x/day Other ________	Yes No Time taken: Unk __ __ : __ __ AM PM
________________	____ mg	PO Other ______	Daily BID TID 4x/day Other ________	Yes No Unk Time taken: Unk __ __ : __ __ AM PM
________________	____ mg	PO Other ______	Daily BID TID 4x/day Other ________	Yes No Time taken: Unk __ __ : __ __ AM PM
________________	____ mg	PO Other ______	Daily BID TID 4x/day Other ________	Yes No Time taken: Unk __ __ : __ __ AM PM
________________	____ mg	PO Other ______	Daily BID TID 4x/day Other ________	Yes No Time taken: Unk __ __ : __ __ AM PM

Dialysis (Historical)

Current Access type:

HD Catheter

AV Fistula/Graft

Other current access not being used in dialysis: ________________________ ________________________

Access location:

Upper Arm

Forearm

Chest

Date of access placement/formation (if known):

__ __ / __ __ / __ __

Date of 1st Dialysis (or approximate years on dialysis):

__ __ / __ __ / __ __ or Number of years: _____

Dialysis schedule:

M/W/F

T/Th/Sa

Dialysis shift:

1st

2nd

3rd

4th

Nocturnal

Other (write-in):________

Feel in the following vital signs and laboratory values, if known. Check ‘Unk’ if not available or unknown.

Session prior to event

Pre-event

First labs after event

Date

Unk

Unk

Unk

Temp C F

Unk

Unk

Unk

HR

Unk

Unk

Unk

BP

Unk

Unk

Unk

RR

Unk

Unk

Unk

SpO2

Unk

Unk

Unk

Weight lbs kg

Unk

Unk

Unk

Na

Unk

Unk

Unk

K

Unk

Unk

Unk

BUN

Unk

Unk

Unk

Creatinine

Unk

Unk

Unk

Calcium

Unk

Unk

Unk

Magnesium

Unk

Unk

Unk

Phos

Unk

Unk

Unk

Albumin

Unk

Unk

Unk

WBC

Unk

Unk

Unk

Hemoglobin:

Unk

Unk

Unk

pH

Unk

Unk

Unk

lactate

Unk

Unk

Unk

	Session prior to event	Pre-event	First labs after event
Other important labs: __________________	Unk	Unk	Unk
Other important labs: __________________	Unk	Unk	Unk
Other important labs: __________________	Unk	Unk	Unk

Did patient miss any dialysis sessions in week or month prior to event?
In a week prior to event? In a month prior to event?	Yes	No	If yes, how many in preceding week _____________
	Yes	No	If yes, how many in preceding month _____________
Did patient have any hospitalizations in week prior to event?	Yes	No	Date: ____________ Reason for admission: ______________________________

Event
Station Number:	______
Dialysis Start Time:	__ __ : __ __ AM PM			Stop time:	__ __ : __ __ AM PM
Event date/time:	__ __ / __ __ / __ __ Day of week: __________		__ __ : __ __ AM PM Time into dialysis session: __________min

Staff assigned to patient during session event occurred (first and last initials only) and role	_________________ RN/BSN	Tech	Other (write-in):____________________
	_________________ RN/BSN	Tech	Other (write-in):____________________
	_________________ RN/BSN	Tech	Other (write-in):____________________
	_________________ RN/BSN	Tech	Other (write-in):____________________

Did the patient receive any of the following medications during dialysis?
Name	Dose	Route	Time		Lot# (if known)
Heparin	_____ mg Units	IV IM PO	__ __ : __ __	AM PM	#__________ Unknown
Hectorol (Cholecalciferol)	_____ mg Units	IV IM PO	__ __ : __ __	AM PM	#__________ Unknown
Erythropoetin or darbopoeitin alpha	_____ mg Units	IV IM PO	__ __ : __ __	AM PM	#__________ Unknown
Ferrous/-ic Select formulation: sucrose dextran gluconate	_____ mg Units	IV IM PO	__ __ : __ __	AM PM	#__________ Unknown

List all other medications given during dialysis, including dose, route, lot and time of administration (if known):
Name: _____________	Dose: _____ mg U	Route: IV IM PO	Lot #: _____	Time: ____ : ____ AM PM
Name: _____________	Dose: _____ mg U	Route: IV IM PO	Lot #: _____	Time: ____ : ____ AM PM
Name: _____________	Dose: _____ mg U	Route: IV IM PO	Lot #: _____	Time: ____ : ____ AM PM
Name: _____________	Dose: _____ mg U	Route: IV IM PO	Lot #: _____	Time: ____ : ____ AM PM

Dialyzer details:
Dialyzer type:	Brand: _______________		Lot: _______________			Tubing type: _______________
Sterilization method:	________________			Dialysis machine type:			________________
Dialysis Bath:	________________
Acid concentrate used:	Brand:_______________				Lot:_________________
Bicarbonate concentrate used:	Brand: _______________				Lot: _______________

Was circuit primed with saline before initiation of dialysis?	Yes	Volume: _____ mL	Brand: __________	Lot: ___________
	No
	Unknown
Was a prime given back to the patient?	Yes	If yes, what volume was given back to the patient? _____ mL
	No
	Unknown
Was circuit primed with heparin before initiation of dialysis?	Yes	Dose: _____ units	Brand: __________	Lot: ___________
	No
	Unknown

Did the patient have any of the following signs or symptoms prior to or during dialysis?
Clinical Sign	Prior to Initiation of Dialysis	During Dialysis	Time of Sign/ Symptom	or	# of minutes into dialysis session
Chest pain	Yes No Unknown	Yes No Unknown			_____ minutes
Bradycardia	Yes No Unknown	Yes No Unknown			_____ minutes
Tachycardia	Yes No Unknown	Yes No Unknown			_____ minutes
Pulselessness	Yes No Unknown	Yes No Unknown			_____ minutes
Palpitations	Yes No Unknown	Yes No Unknown			_____ minutes
Dizzyness	Yes No Unknown	Yes No Unknown			_____ minutes
Extremity swelling/edema	Yes No Unknown	Yes No Unknown			_____ minutes
Hypotension	Yes No Unknown	Yes No Unknown			_____ minutes
Dyspnea, Apneic or agonal respirations	Yes No Unknown	Yes No Unknown			_____ minutes
Wheezing	Yes No Unknown	Yes No Unknown			_____ minutes
Cough	Yes No Unknown	Yes No Unknown			_____ minutes
Fever	Yes No Unknown	Yes No Unknown			_____ minutes
Diaphoresis	Yes No Unknown	Yes No Unknown			_____ minutes
Facial/lip swelling	Yes No Unknown	Yes No Unknown			_____ minutes
Urticaria/hives	Yes No Unknown	Yes No Unknown			_____ minutes
Pruritis	Yes No Unknown	Yes No Unknown			_____ minutes
Nausea/Vomiting	Yes No Unknown	Yes No Unknown			_____ minutes
Numbness/tingling	Yes No Unknown	Yes No Unknown			_____ minutes
Blurry vision/diplopia	Yes No Unknown	Yes No Unknown			_____ minutes
Other:_______________	Yes No Unknown	Yes No Unknown			_____ minutes
Other:_______________	Yes No Unknown	Yes No Unknown			_____ minutes

Resuscitation
Was CPR Initiated? If yes, for how long?	Yes No		Duration:		______ min	Continued through EMS transfer

Medications given during resuscitation:	Name: ________________ Dose:_______ mg units Route: IV IM Name: ________________ Dose:_______ mg units Route: IV IM Name: ________________ Dose:_______ mg units Route: IV IM Name: ________________ Dose:_______ mg units Route: IV IM
Was blood glucose checked? If yes, what was the value?	Yes No Unknown	Value:	_______ mg/dL

If a defibrillator or other similar device capable of detecting a rhythm was used, was a shockable rhythm detected?		Yes No Unknown If known, what rhythm? ____________________		Were shocks delivered?		Yes No Unknown If yes, how many? ________________
Was intubation attempted? If yes, by whom.	Yes No Unknown		RN MD EMS Other:____________		Was intubation successful? (circle)		Yes No Unknown
Was airway edema noted at intubation?	Yes No Unknown

Outcome
Did patient survive?	Yes No, died Unknown
If No, location of death:	dialysis clinic EMS hospital other: ____________________________
If No, cause of death	_____________________________ Unknown
If patient survived, were they admitted to the hospital?	Yes No Unknown If yes, where? ICU wards Other:______________

Hospital Data (if applicable)
Was patient pulseless upon arrival?	Yes No Unknown
Were blood cultures obtained?	Yes No Unknown	If yes, what were the results?	Positive Result:___________________ Negative Unknown
List and describe any significant details of the hospitalization:
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Medical Examiner Records (if applicable)

What was determined as the cause of death?

List any relevant results:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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