PATIENT DETAIL Complete for each patient in the sample identified for review. Last Name: First Name: Middle Initial: Medical Record #

Transcription

1 ehepqual Data Collection Tool This Data Collection Tool should be used to aid the extraction of data from each patient s medical record prior to manually entering the data into the ehepqual system. To upload data using Excel or XML, refer to instructions located on website under Reference Materials in ehepqual Project Data Import Guide. Refer to ehepqual Chart Review Step-by-Step Process document for instructions for the entire review process. Note that the review period (January 1, December 31, 2017) is different from the data collection period (January 1, 2017 June 30, 2018). The review period is used to define which patients are eligible for review. The data collection period refers to the period during which data are being collected. PATIENT DETAIL Complete for each patient in the sample identified for review Last Name: First Name: Middle Initial: Medical Record # Gender of the patient Male Female F->M Transgender M->F Transgender Date of Birth (mm/dd/yyyy) / / Race/Ethnicity (check only one box) White non-hispanic Asian More than one race or ethnicity Black non-hispanic American Indian/Alaska Native Hispanic Native Hawaiian/Other Pacific Islander Risks / Exposures (check all that apply) Current or past IDU Intranasal illicit drug use Hemodialysis Tattoo in an unregulated setting Received blood before 1992 Recipients of Clotting Factor prior to 1987 HIV positive Chronic liver disease of unexplained etiology History of incarceration NONE OF THE ABOVE

2 HEPATITIS C SCREENING AND MANAGEMENT (PAGE 1 OF 3) 1.1) Is patient HCV antibody positive? Unknown 1.1.1) Enter date of most recent positive antibody test / / No date documented 1.2) Was an HCV RNA test performed Ideally, patients completing treatment should be tested at during review period? least 3 times - once after positive antibody test, but prior to treatment, once at the end of treatment and once at least 12 weeks after treatment completion. If more than 10 RNA tests, include first positive and then the 9 most recent results. List all tests during Data Collection Period (1/1/17 6/30/18) If viral load is below limits of quantification or undetectable (e.g.: <15 ND or < 15 D), 0 should be recorded as quantitative result. Test Date Quantitative Result or Qualitative Result 1. / / Positive Negative If all 2. / / Positive Negative quantitative 3. / / Positive Negative & qualitative 4. / / Positive Negative results are 5. / / Positive Negative negative, skip 6. / / Positive Negative to Substance 7. / / Positive Negative Use Screening 8. / / Positive Negative section. 9. / / Positive Negative 10. / / Positive Negative 1.3) Was HIV test ever performed? Test can be from before review period. If patient was ever HIV+, but viral load Go to currently undetectable, record HIV+ test date next section 1.3.1) What was the most recent HIV test result? Positive Negative 1.3.2) Most recent HIV test date / / No date documented 1.4) Was the patient assessed for active HBV infection by HBsAg during the data collection period? Unknown 1.4.1) Enter the date of the most recent HBsAg test (If had HBsAg test both before and after initiation of HCV treatment, enter most recent date prior to HCV treatment initiation): / / 2

3 HEPATITIS C SCREENING AND MANAGEMENT (PAGE 2 OF 3) 1.5) Did the patient receive a standardized assessment of alcohol use either within 12 months prior to the first positive HCV RNA test or during the data collection period? (Any valid assessment tool is acceptable) 1.5.1) Enter the standardized alcohol assessment date (if more than one, enter date closest to the end of data collection period): / / 1.5.2) Was the patient an alcohol consumer? (Use timeframe specified in assessment tool) 1.5.3) Did the patient receive counseling regarding alcohol use either within 12 months prior to the first positive HCV RNA test or during the data collection period? ) Enter the alcohol counseling date (if more than one, enter date closest to the end of data collection period): / / 1.6) Was the patient seen by an HCV-experienced provider? 1.6.1) Provider Name: 1.7) Was the patient evaluated for fibrosis either within 12 months prior to the first positive HCV RNA test or during the data collection period? 1.7.1) Enter the fibrosis evaluation date: (If more than one, enter date closest to the end of the data collection period) / / 3

4 HEPATITIS C SCREENING AND MANAGEMENT (PAGE 3 OF 3) 1.8) Was the patient assessed for barriers to treatment adherence prior to treatment initiation? 1.8.1) Enter the treatment barriers assessment date: / / (if more than one, enter date closest to end of data collection period) 1.9) Was the patient treated for HCV during the data collection period? List all medications below: Ribavirin (Copegus), Daclatasvir (Daklinza), Sofosbuvir & Velpatasvir (Epclusa), Ledipasvir/Sofosbuvirn (Harvoni), Glecaprevir/Pibrentasvir (Mavyret), Simeprevir (Olysio), Pegylated Interferon (Pegasys), Sofosbuvir (Sovaldi), Ombitasvir/Partaprevir/Ritonavir (Technivie), Ombitasvir/Paritaprevir/Ritonavir (Viekira Pac/XR), Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi), Elbasvir/Grazoprevir (Zepatier) Medication Name Start Date Stop Date 1. / / / / 2. / / / / 3. / / / / 4. / / / / 5. / / / / 1.10) Did the patient complete HCV treatment during the data collection period? 1.11) Was genotype testing performed prior to treatment initiation? ) What was the genotype test result? (Choose one) 1a 1b Mixed Genotype ) Specify mixed combination ) Enter the genotype test date: / / 1.12) Was a quantitative assessment of treatment adherence performed while on treatment? Include pill counts, DOT, etc. Don t include RNA viral load ) Enter the date of the quantitative treatment adherence assessment (if more than one, enter date closest to end of data collection period): / / 4

5 SUBSTANCE USE SCREENING Was substance use discussed either in the 12 months prior to the first positive HCV RNA test or during the data collection period? Enter the substance use assessment date (if more than one, enter date closest to end of data collection period): / / Was substance use identified? Current user (Within 6 mos) Past user only (Over 6 mos) None Not documented When was the last time substance(s) was/were used? 6-12 mos mos Over 24 mos Was relapse prevention or ongoing treatment discussed? Inject Intranasal Smoked Heroin Abuse No use Cocaine/Crack Abuse No use Hallucinogens (PCP, LSD, other) Abuse No use Prescription opioids (vicodin, codeine) Abuse No problematic use No use Crystal Methamphetamine Abuse No use Amphetamines Abuse No use Benzodiazepines Abuse No problematic use No use Ecstasy Abuse No use Inhalants (glue, nitrous) Abuse No use Ketamine Abuse No use Other Abuse No use Specify Was harm reduction (overdose prevention, safer injection practices/syringe access) discussed? Was the patient in treatment during the data collection period? Yes No Detoxification unit What action was taken? Residential treatment Referral made Out-patient non-methadone No documented referral 12-step self help Medication-assisted therapy Other Detoxification unit Specify Residential treatment Out-patient non-methadone 12-step self help Medication-assisted therapy Other Specify 5