TIME 1 MARCH 2005 AUGUST 2006 Nursing Home Nurse Practitioner Study - Chart Abstraction Form

Transcription

1 TIME 1 MARCH 2005 AUGUST 2006 Nursing Home Nurse Practitioner Study - Chart Abstraction Form Researcher s name: Resident s Study ID: Place and date ID label here 1. Admitted to NH from: [1 ] hospital [2] home [3 other nursing home 2. [1] Date & time of admission to NH: (dd/mm/yy) / / [2] Time: am/pm 3. Discharged from NH to: [1] deceased [2] N/A (still a resident 4. [1] Date & time of discharge/death: (dd/mm/yy) / / [2] Time: am/pm 5. Sex: [1] female [2] male 6. Age in years: at last month of data collection period or age at death 7. Advanced Care Directives: a) Comfort Care and/or Limited Therapeutic Care b) Hospitalize and/or Resuscitate c) None 8. Height: (most recent) (meters) 9. Weight: (most recent) (kg) Edited July 22/08 TIME 1 1

2 10. Allergies: [1] Egg [2] Penicillin 11. Immunization: a) Pneumococcal vaccine [1] Yes [2] No [3] Unknown [4] Refused (within last 6 years) b) Influenza vaccine [1] Yes [2] No [3] Unknown [4] Refused (within last 12 months) 12. Ambulation: (in last month) [1] Walks independently [2] Walks with assistance [3] Uses a cane or walker for mobility [4] Sits in chair [5] Bed-ridden (acutely ill/near death) 13. Diagnoses (from Beers) Check all that apply [1] Anorexia and malnutrition [2] Arrhythmias (include all types) [3] Bladder outflow obstruction [4] Blood clotting disorders or receiving anticoagulant therapy [5] Chronic constipation [6] Cognitive impairment /confusion [7] COPD [8] Stress incontinence [9] Depression [10] Gastric or duodenal ulcers [11] Heart failure [12] Hypertension [13] Insomnia [14] Obesity [15] Parkinson s disease [16] Seizures, seizure disorder or epilepsy [17] SIADH*//hyponatremia [18] Syncope *syndrome of inappropriate anti-diuretic hormone Edited July 22/08 TIME 1 2

3 14. Resource Use/ Consults: Specialty/ Reason Frequency Department (if available) (no.of times for each consult reason within timeframe) [1] Audiology 1) [2] Cardiology 1) [3] Dentistry 1) [4] ENT 1) [5] Foot Care 1) Nurse [6] Chiropodiatry1) [7] Geriatrician 1) [8] Geriatric 1) Nurse Spec. (CNS/NP) [9] Hospice 1) Edited July 22/08 TIME 1 3

4 [10] Neurology 1) [11] Opthamology 1) [12] Optometry 1) [13] Orthopedics 1) [14] Mental 1) Health Nurse [15] Psychiatrist 1) [16] Speech 1) Therapy [17] 1) 4) 5) Edited July 22/08 TIME 1 4

5 15. Diagnostic Tests: (Specify) Frequency [1] Ultrasound: [a] Abdominal 1) [b] Pelvic 1) 3) [2] Scan: [a] BMD 1) [b] CT 1) [c] MRI 1) [d] PET 1) [3] X-rays [a] Chest 1) [b] Limb 1) [c] Skull 1) [4] 1) (eg.: ECHOcardiogram) 2) 3) Edited July 22/08 TIME 1 5

6 16. Procedures: Frequency In-house Off-site (Please specify, e.g.: sutures, dialysis, ECT) 1) [2] [3] [4] 2) [2] [3] [4] 3) [2] [3] [4] 4) [2] [3] [4] 5) [2] [3] [4] 17. Medications: (include regularly prescribed or administered only. If PRNs are used on regular basis, i.e. 3 times per week, please record) Note: If drug initiated before data collection time frame, use 1 st month of the time period. Name of drug Dose Frequency Date started Date discont d Remains Ingested On Drug _ Edited July 22/08 TIME 1 6

7 Name of drug Dose Ingested Frequency Date started Date discont d Remains On Drug _ Edited July 22/08 TIME 1 7

8 18. Emergency Room Transfer Record (please complete for each unplanned transfer to ER) 1. Means of transfer to ER 2. Means of discharge from Emergency Room N/A (deceased) [4] 3. Reason for transfer to ER 4. Diagnosis in ER: No Diagnosis 5. Length of Time in Emergency Room and/or Hospital Date & time of admission to ER: (dd/mm/yy) Time am/pm Date & time of discharge from ER to NH: (dd/mm/yy) Time am/pm (If not available, use arrival date &time at nursing home) Date & time of admission from ER to hospital: (dd/mm/yy) Time am/pm Date & time of discharge from hospital: (dd/mm/yy) Time am/pm Unknown Date & time of death: (dd/mm/yy) Time am/pm Unknown [1] Total time in ER in hours: 6. PDRM (Preventable drug related morbidity) Outcomes YES NO (Please fill out a PDRM form for each emergency visit.) Edited July 22/08 TIME 1 8

9 19. Emergency Room Transfer Record (please complete for each transfer to ER) 1. Means of transfer to Emergency Room 2. Means of discharge from Emergency Room N/A (deceased) [4] 3. Reason for transfer 4. Diagnosis in ER: No Diagnosis 5. Length of Time in Emergency Room and/or Hospital Date & time of admission to ER: (dd/mm/yy) Time am/pm Date & time of discharge from ER to NH: (dd/mm/yy) Time am/pm (If not available, use arrival date & time at nursing home) Date & time of admission from ER to hospital: (dd/mm/yy) Time am/pm Date & time of discharge from hospital: (dd/mm/yy) Time am/pm Date & time of death: (dd/mm/yy) Time am/pm Total time in ER in hours: 6. PDRM (Preventable drug related morbidity) Outcomes YES NO (Please fill out a PDRM form for each emergency visit.) Edited July 22/08 TIME 1 9

10 20. Emergency Room Transfer Record (please complete for each transfer to ER) 1. Means of transfer to Emergency Room 2. Means of discharge from Emergency Room N/A (deceased) [4] 3. Reason for transfer 4. Diagnosis in ER: No Diagnosis 5. Length of Time in Emergency Room and/or Hospital Date & time of admission to ER: (dd/mm/yy) Time am/pm Date & time of discharge from ER to NH: (dd/mm/yy) Time am/pm (If not available, use arrival date &time at nursing home) Date & time of admission from ER to hospital: (dd/mm/yy) Time am/pm Date & time of discharge from hospital: (dd/mm/yy) Time am/pm Date & time of death: (dd/mm/yy) Time am/pm Total time in ER in hours: 6. PDRM (Preventable drug related morbidity) Outcomes YES NO (Please fill out a PDRM form for each emergency visit.) Edited July 22/08 TIME 1 10

11 21. Emergency Room Transfer Record (please complete for each transfer to ER) 1. Means of transfer to Emergency Room 2. Means of discharge from Emergency Room N/A (deceased) [4] 3. Reason for transfer 4. Diagnosis in ER: No Diagnosis 5. Length of Time in Emergency Room and/or Hospital Date & time of admission to ER: (dd/mm/yy) Time am/pm Date & time of discharge from ER to NH: (dd/mm/yy) Time am/pm (If not available, use arrival date & time at nursing home) Date & time of admission from ER to hospital: (dd/mm/yy) Time am/pm Date & time of discharge from hospital: (dd/mm/yy) Time am/pm Date & time of death: (dd/mm/yy) Time am/pm Total time in ER in hours: 6. PDRM (Preventable drug related morbidity) Outcomes YES NO (Please fill out a PDRM form for each emergency visit.) Edited July 22/08 TIME 1 11

12 22. Emergency Room Transfer Record (please complete for each transfer to ER) 1. Means of transfer to Emergency Room 2. Means of discharge from Emergency Room N/A (deceased) [4] 3. Reason for transfer No Diagnosis 4. Diagnosis in ER: 5. Length of Time in Emergency Room and/or Hospital Date & time of admission to ER: (dd/mm/yy) Time am/pm Date & time of discharge from ER to NH: (dd/mm/yy) Time am/pm (If not available, use arrival date& time at nursing home) Date & time of admission from ER to hospital: (dd/mm/yy) Time am/pm Date & time of discharge from hospital: (dd/mm/yy) Time am/pm Date & time of death: (dd/mm/yy) Time am/pm Total time in ER in hours: 6. PDRM (Preventable drug related morbidity) Outcomes YES NO (Please fill out a PDRM form for each emergency visit.) Edited July 22/08 TIME 1 12