VACS 3 Chart Review Final 1 Initials-last 4
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1 VACS 3 Chart Review Final 1 Initials-last 4 An space designated as is to be used to enter a date. List all dates as MM/DD/YY. If you don't have a day or a month use 00 in designated space. A space designated as is meant to be checked if condition is present. A space designated as is meant to have a written response Date of Extraction: Start Time: End Time: Earliest Record Date: Patient Name: Site (circle one): Cleveland/Manhattan/Houston Latest Record Date: SSN: Enrollment Date: Date First HIV Positive Test: Data Available (circle all that apply): Inpatient/ IDClinic/ Nutrition/ Psychiatric Notes Pages: Start End /Special Medicine MEDICAL CONDITION Please circle the correct time frame that the diagnosis was clinically established: Pre-Enroll/Post- Enroll plus Pre-HIV diagnosis / Post-HIV diagnosis. 1 Bacterial Pneumonia Date (first recurrence after post-enroll): Organism (post-enroll): CXR sputum culture 2 Cancer Metastatic Tissue Bx Type of Cancer Date of Dx Circle one ** HIV only Kaposi's Sarcoma Basal Cell Skin Melanoma Skin CNS Lymphoma Hodgkins Lymphoma Non Hodgkins Lymphoma Lung Cancer Colon Cancer Rectal Cancer Prostate Cancer
2 VACS 3 Chart Review Final 2 Initials-last 4 3 Candidiasis (Thrush) Thrush Esophageal 4 Cirrhosis (Liver Failure) Etiology: ADR/ Alcohol/ Viral/ Ascites? Liver Bx? Date Liver Bx: Varices? 5 Coccidioidomycosis Antigen? Basis: Hist or Cytology / Culture 6 Congestive Heart Failure (CHF) EF (%) Rt/Lt/Diast Date of Study 7 Coronary Artery Disease (CAD) Stress Test Cath CABG Angina: 8 Cryptococcosis (Crypto) Meningitis? Antigen? Basis: Hist or Cytology / Culture
3 VACS 3 Chart Review Final 3 Initials-last 4 9 Cryptosporidiosis Exacerbaton (post-enroll) Basis: Hist or Cytology / Culture 10 Cytomegalovirus (CMV) Retinitis Antibody* Basis: Hist or Cytology Vision Loss/Impair: *Positve Antibody Only - Do not use Must also have symptoms 11 Dementia (HIV enceph., HAD, MCMD) Cognitive Motor Causes? 12 Diabetes Etiology: ADR/ Family History/ Obesity Based on Meds Only 13 Herpes simplex 14 Herpes zoster (shingles) Effected Sites/Distribution:
4 VACS 3 Chart Review Final 4 Initials-last 4 15 Histoplasmosis Antigen? Basis: Hist or Cytology / Culture 16 Hypertension 17 Isosporiasis Biopsy? 18 VOID NO #18 19 Myocardial Infarction Positive Enzymes and/or Troponin ECG ( for diagnosing ) 20 Osteopenia Method of Dx: 21 Osteoporosis (spine or hip fracture) Site of Fx: 22 Mycobacteriosis (MAI, MAC, etc) Culture
5 VACS 3 Chart Review Final 5 Initials-last 4 23 Pancreatitis Etiology: ADR/ Alcohol/ Method of Dx: List : 24 Peripheral Vascular Disease Method of Dx: 25 Peripheral Neuropathy Etiology: ADR/ Diabetes/ HIV/ List : 26 Pneumocystis carinii Pneumonia (PCP) Basis: Hist or Cytology Bronch 27 Progressive Multifocal Leukoencephalopathy (PML) Basis: Hist or Cytology Exacerbation (post-enroll) 28 Pulmonary Disease (COPD/Bronchitis/Emphysema/Asthma) Childhood Asthma
6 VACS 3 Chart Review Final 6 Initials-last 4 29 Renal Dialysis (on HD or PD) 30 Salmonellosis Culture 31 Sepsis (Bacterial) Pos/Total Bld Cxs / Organism (post-enroll): Endocarditis Suspected? ECHO Done? Echo Positive? Yes or No 32 Sleep Apnea 33 Stroke (Neurologic loss>24 hours) CT Pos MRI Pos 34 Toxoplasmosis In Brain? Basis: Hist or Cytology 35 Transient Ischemic Attack (<24 hours)
7 VACS 3 Chart Review Final 7 Initials-last 4 36 Tuberculosis Culture 37 Wasting (cachectic) >10% of body weight or >20 lbs lost Presumptive "wasting"in chart Causes Over # Months 38 Describe PSYCHIATRIC CONDITIONS Psych Dx' box if diagnosis is listed as present by a psychiatrist, psychologist, or social worker 39 Depression on antidepressants Date (post-enroll only) Exacerbation (post-enroll) Depression Screen Type of Screen: Prime-MD, Oryx, General,. Circle One: Positive / Negative Repeat Screen (post-enroll) Circle One: Positive / Negative (for repeat screen) (Screen for post-enroll only) 40 Suicidal Ideation Actual Attempt? Date (post-enroll only) Repeat Attempt (post-enroll)
8 VACS 3 Chart Review Final 8 Initials-last 4 41 Schizophrenia Exacerbation (post-enroll) 42 PTSD Exacerbation (post-enroll) PTSD Screen Type of Screen: Oryx, General,.. Circle One: Positive / Negative Repeat Screen (post-enroll) Circle One: Positive / Negative (for repeat screen) (Screen for post-enroll only) 43 Anxiety Disorder Exacerbation (post-enroll) 44 Alcohol Abuse or Dependence Exacerbation (post-enroll) 45 Illicit Drug Abuse or Dependence Exacerbation (post-enroll) 46 Major Psych Disturbances ( POST ENROLL DATES ONLY ) Date: Date: Date: Date: Date: Condition Condition Condition Condition Condition
9 VACS 3 Chart Review Final 9 Initials-last 4 ADVERSE DRUG REACTIONS Any Adverse Drug Effect Suspected or Noted? Be sure to circle "ADR" above if cirrhos rhosis 47 diabetes, pancreatitis, or peripheral neuropathy thought at least in part due to ADR. Medication Suspected Date (Post-Enroll Only) Abacavir Hypersensitivity 60 days from start? Anemia macro, micro, normo Chemical Hepatitis Diarrhea Drug Rash Fat Redistribution* Hyperlipidemia Kidney Stones Indinavir noted? Lactic Acidosis** Nausea or Vomiting Renal Insufficiency Rhabdomyolysis * names used for fat redistribution include protease paunch, buffalo hump, lipodystrophy. Please describe condition if listed **Note if patient is considered symptomatic or asymptomatic and list highest Lactate level RACE, RISKS, ADDICTIONS, BEHAVIORS Race 48 Note: Patient may be White and Hispanic or Black and Hispanic Black/AA White Asian Native Hawaiian or Pacific Islander American Indian or Alaska Native Ethnicity is Hispanic Latino (can also be Black/White etc) 49 Risk Behavior (may check more than one) Men who have sex with Men Heterosexual exposure (multiple partners or partner known positive) Intravenous Drug Use Transfusion
10 VACS 3 Chart Review Final 10 Initials-last 4 50 Body Mass Index: Date List data given closest to the enrollment date Height: (inches) Wt: (pounds-round up) % Ideal: (to nearest hundredth) BMI: Ideal Wt: (to nearest tenth) 51 Family History of Heart Disease: MI or Sudden Death in 1st degree relative.if female must occur before 65, male before 55 yrs. 52 Intentional Treatment Interruption of ARVs Patient requested Provider requested ( POST-ENROLL ONLY ) Nonadherence No current ADR or drug interaction, but want to avoid ADR or drug interaction Current ADR or drug interaction Failure to respond to treatment Patient doing well. Sustained high CD4 count. Clinical Trial (or structured treatment interruption) Start Date End Date (Post-enrollment dates only) Recurrent? 53 Nonadherence to VISITS OR HOSPITALIZATIONS (Post-enrollment only) No Problem / Occasional Problems/ Frequent Problems (Circle One) >2 Missed Appointments Left Hospital Against Medical Advice (AMA) or Unauthorized Absence (UA) 54 Adherence to MEDICATIONS (only check if ARV adherence is specifically mentioned) (Post-enrollment only) No Problem / Occasional Problems/ Frequent Problems (Circle One) 55 Illicit Drug Use Past only if has not used in more than 12 months Drug Used: Cocaine/Heroin/Marijuana/Amphetamines/Sedative Hypnotics Barbituates/LSD/ Benzodiazepines/ (circle all that apply) List Current and Past Past Only Documented as No Use No Data Describe Problem Stopped/Curtailed Intake Due to Problems Tried to stop or curtail but wasn't able to
11 VACS 3 Chart Review Final 11 Initials-last 4 56 Alcohol Use/Abuse Past only if has not had a drink in more than 12 months Current and Past Past Only Documented as No Use No Data Describe Problem #years of drinking Stopped/Curtailed Intake Due to Problems Tried to stop or curtail but wasn't able to current drinking: # Drinks/week Max # Drinks/day At height of drinking: # Drinks/week Max # Drinks/day 57 Smokes Cigarettes Past only if has not had a cigarette in more than 12 months Current and Past Past Only Documented as No Use No Data Describe Problem Current smoking packs/day At height of smoking packs/day Stopped/Curtailed Intake Due to Problems Tried to stop or curtail but wasn't able to # years of smoking pack/yrs
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