Form Ca1 - Wihs Medical Record Abstraction (Page 2 of 2) in pdf

Form Ca1 - Wihs Medical Record Abstraction Page 2

WIHS ID#:

YES

C2d. Copy of autopsy report obtained?

1 *

Medical Examiner’s (ME) Case?

C2e.

1 **

*PHOTOCOPY DEATH CERTIFICATE/AUTOPSY REPORT

**ORDER COPY OF ME REPORT

C3. Discharge diagnoses:

List any AIDS-related illness from the WIHS Event Code List and abstract them:

Event Code:

i. |___| |___| |___|

1st dx

i. |___| |___| |___|

2nd dx

i. |___| |___| |___|

3rd dx

4th dx

i. |___| |___| |___|

5th dx

i. |___| |___| |___|

SECTION D: PROCEDURES AND TESTS

YES

D1.

Surgical Procedures ...............................................

(If YES, Complete Form CA2)

D2.

Endoscopy/Bronchoscopy .....................................

(If YES, Complete Form CA3)

D3.

Cytology/Pathology/Biopsy ...................................

(If YES, Complete Form CA4)

D4.

Microbiology .........................................................

(If YES, Complete Form CA5)

D5.

Cranial CT or MRI scan(s) ....................................

(If YES, Complete Form CA6)

D6.

Cerebrospinal Fluid ...............................................

(If YES, Complete Form CA7)

WIHS Medical Record Abstraction Form CA1 -- Hospital Information -- Version 02/01/96 - Page 2 of 2

Form Ca1 - Wihs Medical Record Abstraction Page 2