Medical Record Abstraction Form
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1
2A. HEALTHCARE FACILITY - ADMINISTRATIVE
F. INJURIES:
(
)
CHECK ALL THAT APPLY
A1. CDC
|__|__|__|__|
E
FACILITY CODE
YE INJURY
A2. F
: ____________________________________________
T
ACILITY NAME
YMPANIC MEMBRANE RUPTURE
A3. F
: |__|__|__|__|__|__|__|__|__|
T
/
ACILITY PATIENT MEDICAL RECORD NUMBER
RAUMATIC BRAIN INJURY
CONCUSSION
I
NHALATION INJURY
B. PATIENT INFORMATION
B
/
LAST LUNG
PULMONARY CONTUSION
B1. D
: |___|___| - |___|___ | - |___|___|___|___|
ATE OF BIRTH
P
/
NEUMOTHORAX
HEMOTHORAX
M M
D
D
Y
Y
Y
Y
B
/
LAST ABDOMEN
ACUTE ABDOMEN
I
, A
: ______
F BIRTHDATE IS UNKNOWN
PPROXIMATE AGE IN YEARS
)
T
/ H
P
(
INNITUS
EARING
ROBLEMS
CHECK ONE
B2. S
...................................................................
M
F
EX
ALE
EMALE
P
P
-
SYCHOLOGICAL
ROBLEMS POST
BOMBING
B3. I
...
Y
N
DENTIFIED AS RESPONDER OR RESCUE WORKER
ES
O
=
=
/
HN
UE
HEAD
NECK
UPPER EXTREMITY
=
/
=
TA
LE
THORAX
ABDOMEN
LOWER EXTREMITY
B4. I
..................
Y
N
DENTIFIED AS SUSPECTED TERRORIST
ES
O
HN
TA
UE
LE U
NKNOWN
C. ARRIVAL STATUS
F
/
.. >
RACTURE
DISLOCATION
C1. M
(
)
S
/
.............. >
ODE OF ARRIVAL AT FACILITY
CHECK ONE
PRAIN
STRAIN
W
/
G
A
....................... >
ALK IN
PERSONAL VEHICLE
ROUND AMBULANCE
BRASION
A
/
P
/
C
..................... >
IR
HELICOPTER
OLICE
LAW ENFORCEMENT
ONTUSION
U
O
(
):
L
/
NKNOWN
THER
TEXT
ACERATION
_____________________________________
....... >
PENETRATING TRAUMA
DATES & TIMES:
C
S
........... >
RUSH
YNDROME
MONTH
DAY
YEAR
MILITARY TIME
A
.................... >
MPUTATION
C2. A
:
RRIVED AT TRIAGE
|___|___| - |___|___ | - |___|___|___|___|
|___|___|___|___|
B
.............................. >
URN
C3. S
:
EEN BY INITIAL PROVIDER
|___|___| - |___|___ | - |___|___|___|___|
|___|___|___|___|
U
O
(
):
NKNOWN
THER
TEXT
_________________________________
C4. I
(
):
P
N
P
NITIAL PROVIDER WAS
CHECK ONE
HYSICIAN
URSE
RACTITIONER
G. INITIAL DISPOSITION AND RESOURCES
P
’
A
O
:
________________________
(
)
HYSICIAN
S
SSISTANT
THER
TEXT
G1. D
(
)
ISPOSITION
CHECK ALL THAT APPLY
C5. T
(
)
(
)
RIAGE LEVEL
CONDITION UPON ARRIVAL
CHECK ONE
T
REATED AND RELEASED
L
EFT WITHOUT EVALUATION
E
(
/
)
MERGENT
LIFE
LIMB THREATENING INJURY
L
EFT AGAINST MEDICAL ADVICE
U
(
2
)
RGENT
REQUIRING TREATMENT WITHIN
HOURS
A
:
DMITTED TO
OPERATING ROOM
N
-
ON
URGENT
INTENSIVE CARE UNIT
BURN UNIT
C6. A
(
)
DMISSION SYSTOLIC BLOOD PRESSURE
CHECK ONE
/
HOSPITAL FLOOR
INPATIENT WARD
UNKNOWN
90
H
L
90
H
MM
G OR MORE
ESS THAN
MM
G
O
:
(
)
THER
TEXT
D. INCIDENT CIRCUMSTANCES: GENERAL
(
)
CHECK ALL THAT APPLY
______________________________________
D1. T
:
C
(
,
,
)
O
YPE BOMBING
ONFINED SPACE
BUS
TRAIN
BUILDING
PEN AIR
T
: E
“
/
”
(
):
RANSFERRED
XPLAIN
WHERE
WHY
TEXT
S
TRUCTURAL COLLAPSE
______________________________________________________
D2. D
:
R
C
B
ISPERSIVES
ADIOLOGICAL
HEMICAL
IOLOGICAL
D
:
IED
DEAD ON ARRIVAL
IN EMERGENCY DEPARTMENT
N
U
ONE
NKNOWN
AFTER ADMISSION
UNKNOWN
E. INCIDENT CIRCUMSTANCES: PATIENT-SPECIFIC
(T
): _______________________________
OTHER
EXT
E1. L
/ P
(
):
OCATION
ROXIMITY OF PATIENT DURING INCIDENT
TEXT
____________________________________________________________________
G2. M
:
EDICAL RESOURCES
( CHECK ALL THAT APPLY )
E2. E
(
): ____________________________________
XPLAIN WHAT HAPPENED
TEXT
BLOOD PRODUCTS
ENDOTRACHEAL INTUBATION
E3. M
(
)
ECHANISM OF INJURY
CHECK ALL THAT APPLY
:
-
IMAGING STUDIES
X
RAY
CT
ULTRASOUND
C
/
/
UT
PIERCED
STRUCK BY
FRAGMENTS
OTHER DEBRIS
UNKNOWN
): ______________________________________
OTHER (TEXT
S
(
)
TRUCK FIXED OBJECT
PUSHED OR KNOCKED AGAINST OBJECT
__________________________________________
C
(
)
RUSHED
CAUGHT BETWEEN TWO OBJECTS
G3. S
:
PECIALISTS
( CHECK ALL THAT APPLY )
B
URNED BY
EXPLOSION
SECONDARY FIRE
CHEMICAL
UNKNOWN
G
/
S
T
ENERAL
TRAUMA
URGEON
HORACIC SURGEON
I
/
NHALED
TOXIC GAS
FUMES
PARTICULATE MATTER
UNKNOWN
N
O
EUROSURGEON
RTHOPEDIC SURGEON
R
ADIATION EXPOSURE
UNKNOWN
ENT S
U
URGEON
ROLOGIST
O
(
):
___________________________________________________
THER
TEXT
UNKNOWN
: _______________
(
)
_____________________
OTHER
TEXT
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