Form 1 Medical chart/record abstraction sample selection guide

R yan White HIV/AIDS Program Outcomes and Expanded Insurance CoverageStudy – Chart Abstraction Form OMB Number (0906-XXXX)

Expiration Date: XX-XX-201X

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

Background

The chart abstraction will be conducted by the Abt Team - JSI staff on a sample of clients at each of the participating sites. The information will primarily be abstracted from the site’s electronic health record (EHR) and billing systems and recorded in an online data collection system developed by Abt.

The review period for the chart abstraction will be from July 1, 2013 through June 30, 2016 to allow for adequate data to support the analysis. We will abstract information from each service provided to the sampled client during this time period (medical visits, core and support services, tests). When the chart review is completed, the client’s information will be uploaded on Abt’s secure server. The system will automatically generate the eUCI using information from: the first and third letters of the client’s first name, the first and third letters of the client’s last name, the full date of birth (DOB) and gender. Once entered, this information will automatically be converted to the eUCI - and the DOB will be transformed to age. The data entry program will simultaneously delete the name and DOB. Therefore, no personally identifying information will be transferred or saved in this upload (e.g., initials of client and date of birth). The client ID will allow us to link chart abstraction data to the site’s RSR data since the same algorithm to create the unique client ID was applied to both chart abstraction and RSR extract.

This document provides draft screens for Abt’s online data collection system. The system will include seven tabs and a brief overview of each tab is provided below. In general, after completing a screen, abstractors can click “save” to save the information in the system and “continue” to continue to the next screen or tab.

• Client information/demographics: This information is entered one time (static). The information is used to create the unique client ID and document gender, race, ethnicity, HIV risk, date first tested positive and entered care at the site, date of AIDS diagnosis (if applicable), date of ART initiation, Hepatitis status, and gaps in care.

• HIV medical visits: The information shown in this screen will be collected for each visit that occurs during the review period, including those where the client is considered a “no show.” The abstractor will only include visits where a HIV medical provider with prescribing privileges was seen.

• Laboratory testing: The information shown in this screen will be collected for each test that occurs during the review period. The abstractor will enter test information (type of test and date of test) and then to enter another test will client the button “add another test”. The tests will be able to be matched to corresponding HIV medical visits by date.

• Hospitalizations: The information shown in this screen will be collected for each inpatient and emergency department (ED) admission that occurs during the review period. The abstractor will enter dates of visit and reason for the visits. Multiple hospitalizations can be entered by using the button “add another hospitalization” or “add another ED visit”.

• Billing/insurance: Given that billing and insurance information may be collected in a separate system (billing system) from the clinical information (EHR), we have included billing information on a separate screen. This screen includes information on: payers (primary and secondary), type of service, ICD-9/10 codes for service, use of ADAP and client’s poverty level. The billing/coverage information for the service can be linked to the medical visits, etc. by date of service.

• RWHAP core service use: The information shown in this screen will be collected for each core service received during the review period. The abstractor will enter dates of service for the type of service. Multiple visits for the same service can be entered by using the button “add another date”.

• RWHAP support service use: The information shown in this screen will be collected for each support service received during the review period. The abstractor will enter dates of service for the type of service. Multiple visits for the same service can be entered by using the button “add another date”.

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016

Site ID:		Initials of Reviewer:				Date of Review:				Start & end time of chart review (in mins):
__ __ __ __		__ __ __				__ __ / __ __ / __ __				Start: __ __ : __ __ End: __ __ : __ __
First and third letters of first name:		Date of birth:				Current Gender:					Country of birth:
__ __		__ __ / __ __ / __ __ Enter January 1 if month and date are unknown				Male Female Transgender (man to woman) Transgender (woman to man)					US US territory: ________________ Outside the US: _____________ Not available
First and third letters of last name:		State of residence:
__ __		__ __
Race (check all that apply):				Hispanic ethnicity:			HIV risk (check all that apply):
White Black Asian Native Hawaiian/other Pacific Islander Native American/Alaska Native Other: _______________				Yes No			Male who has sex with males (MSM) Injecting Drug Use (IDU) Hemophilia/coagulation disorder Heterosexual contact Receipt of blood transfusion, blood components or tissue Mother with/at risk for HIV (perinatal transmission) Risk factor not reported/not identified
Date 1st tested HIV positive:	Date 1st HIV medical visit at site:				AIDS diagnosis:				Date ART initiated:
__ __ / __ __ □ Date unknown Enter January if month unknown	__ __ / __ __ □ Date unknown Enter January if month unknown				Yes → Date diagnosed: __ __ /__ __ Enter January if month unknown □ Date unknown No				Date initiated: __ __ /__ __ □ Date unknown Enter January if month unknown □ No record of ever being on ART
Gaps in care during the review period:
Is there documentation that the patient had a period of greater than six months between medical visits at this site during the review period? □ Yes □ No → If yes: Date of last visit at this site before gap: __ __ / __ __ Enter January if month unknown Reason for gap in care: □ Lost to follow up □ Transferred care □ Died □ Moved □ Incarcerated □ No documentation □ Other. Describe: ___________________
Death during the review period:
Is there documentation that the patient died during review period? □ Yes □ No → If yes: Date of death: __ __ / __ __ Enter January if month unknown Cause of death: ___________
Remarks:

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016

Date of visit with HIV medical provider with prescribing privileges:					If Female, Pregnancy at visit:
__ __ / __ __ / __ __ Enter 1 in place of day for the 1st visit in the month, 2 for the 2nd visit, etc. Check if client did not show up for the visit: □					□ Yes → On ART: □ Yes □ No, refused □ No □ No, not offered □ No, other
On ART at visit:					Documented ART adherence issue at visit:					Blood pressure readings at visit:
Yes → GO TO ART REGIMEN CREEN No					Yes → if yes: □ Coverage related lapse □ Other adherence issue (specify): __________ No					Systolic: __ __ __ Diastolic: __ __ __
Preventive service delivery during the visit:
Influenza vaccination: □ Yes □ No	Pneumococcal vaccination: □ Yes □ No □ Vaccination up to date					Hepatitis B vaccination: □ Dose 1 □ Dose 2 □ Dose 3 □ Vaccination up to date □ No
Preventive screening during the visit:
STI screening Chlamydia: □ Yes □ No □ Sexually inactive Gonorrhea: □ Yes □ No □ Sexually inactive Syphilis: □ Yes □ No □ Sexually inactive				Hepatitis C screen: □ Yes □ No Hepatitis B screen: □ Yes □ No			Cervical/anal cancer screening: □ Yes □ No
Behavioral Health screening during the visit:
□ Mental health screening		□ Substance use (alcohol/drugs) screening
Conditions indicated in the condition list during visit: (check all that apply)
Diabetes Hypertension Hyperlipidemia			Other cardiovascular disease Hepatitis C Hepatitis B					Mental disorder Substance use disorder AIDS defining opportunistic infection (OI), describe: _____________________
Medications to treat conditions indicated during visit: (check all that apply)
Anti-hypertensives Lipid lowering drugs Insulin Oral medications to treat diabetes			STI treatment Hepatitis C treatment Hepatitis B treatment					PCP prophylaxis MAI prophylaxis Anti-depressants/psychotics Withdrawal management (alcohol, substance use)

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016
ART regimen (check all that apply)
Abacavir (ABC, Ziagen) Amprenavir (APV, Agenerase) Atazanavir (ATV, Reyataz) Atripla (EFV/FTC/TDF) Cobicistat (COBI, Tybost) Combivir (AZT/3TC) Complera (FTC/RPV/TDF) Darunavir (DRV, TMC 114, Prezista) Delavirdine (DLV, Rescriptor) Didanosine (ddl, Videx) Dolutegravir (DTG, Tivicay) Efavirenz (EFV, Sustiva) Elvitegravir (EVG, Vitekta) Emtricitabine (FTC, Emtriva)	Enfuvirtide (ENF, T-20, Fuzeon) Epzicom (ABC/3TC) Etravirine (ETR, Intelence, formerly TMC125) Evotaz (ATV/COBI) Fosamprenavir (FPV, Lexiva) Genvoya (EVG/COBI/FTC/TDF) Indinavir (IDV, Crixivan) Lamivudine (3TC, Epivir) Lopinavir/Ritonavir (LPV/RTV, Kaletra, Meltrex) Maraviroc (MRC, Selzentry) Nelfinavir (NFV, Viracept) Nevirapine (NVP, Viramune) Odefsey (FTC/RPV/TAF) Prezcobix (DRV/COBI) Raltegravir (RAL, Isentress, formerly MK-0518)	Rilpivirine (RPV, Edurant) Ritonavir (RTV, Norvir) Saquinavir (SQV-HGC, Invirase, Fortovase) Stavudine (d4T, Zerit) Stribild (EVG/COBI/FTC/TDF) Tenofovir (TDF, Viread) Tipranavir (TPV, Aptivus) Triumeq (ABC/DTG/3TC) Trizivir (ABC/3TC/AZT) Truvada (FTC/TDF) Zalcitabine (ddC, Hivid) Zidovudine (AZT, Retrovir) Other. Specify: ___________________ Not documented

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016

CD4 counts during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Result: _______ mm³ or _______ % □ Not documented

Viral loads during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Result: _______ copies/mL □ Undetectable □ Not documented

→ Lower limit of detection for viral load test used: _________

Glucose regulation tests during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Type: □ Fasting blood glucose □ Hemoglobin A1c

Result: _______ mg/dL _________ % □ Not documented

Lipid level tests during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Type: □ Cholesterol HDL □ Cholesterol LDL □ Cholesterol Total □ Triglycerides

Result: _______ mg/dL _______ mg/dL _______ mg/dL _______ mg/dL □ Not documented

HIV resistance (genotype/phenotype) test during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Result: □ Resistance reported □ Possible/intermediate resistance reported □ No resistance reported

□ Indeterminate result □ Not documented

Hepatitis B screen during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Result: □ Positive □ Negative □ Not documented

Hepatitis C screen during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Result: □ Positive □ Negative □ Not documented

STI screen during the review period: Enter 1 in place of day for the 1^st visit in the month, 2 for the 2^nd visit, etc.

Date: __ __ / __ __ / __ __ Type: □ Chlamydia □ Gonorrhea □ Syphilis Result: □ Positive □ Negative □ Not documented

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016

Inpatient hospitalizations during the review period: Enter 1 in place of day for the 1^st visit etc.

Intake Date: __ __ / __ __ / __ __ Principal diagnosis (ICD code): ________________ ICD version: □ v9 □ v10

Discharge Date: __ __ / __ __ / __ __ Secondary diagnosis (ICD code): ______________ ICD version: □ v9 □ v10

Emergency department admissions during the review period: Enter 1 in place of day for the 1^st visit etc.

Admission Date: __ __ / __ __ / __ __ Principal diagnosis (ICD code): ________________ ICD version: □ v9 □ v10

Secondary diagnosis (ICD code): _______________ ICD version: □ v9 □ v10

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016
Payers during the review period:
Date of service: __ __ / __ __ / __ __ Enter 1 in place of day for the 1st visit etc. Primary payer for this service: Medicaid Private. Specify carrier/plan: ______________ → check if known to be QHP/marketplace □ Medicare Other public (VA, Tricare, etc.) Other plan. Specify: ___________________ Ryan White HIV/AIDS Program (no other coverage)		Service type: □ OAMC □ Hospitalization □ Core □ Support Secondary payer for this service: Medicaid Private. Specify carrier/plan: ______________ → check if known to be QHP/marketplace □ Medicare Other public (VA, Tricare, etc.) Other plan. Specify: ___________________ Ryan White HIV/AIDS Program (no other coverage)
Diagnostic codes reported during date of service: ICD code:_______________ ICD version: □ v9 □ v10
Poverty level during the review period:
Date reported: __ __ / __ __ Federal Poverty level (FPL): Less than 100% FPL 101-138% FPL 139-200% FPL 201-250% FPL	251-400% FPL 401-500% FPL More than 500% FPL Not documented
ADAP or local health insurance program assistance during the review period:
□ ADAP → Date of eligibility determination: __ __ / __ __ □ Local health insurance program → Date enrolled: __ __ / __ __ Type of assistance: Drug assistance (direct purchase, reimbursement): □ ADAP □ Local health insurance program Premium assistance: □ ADAP □ Local health insurance program Cost sharing support: □ ADAP □ Local health insurance program Other: □ ADAP □ Local health insurance program → Specify: ______________________________

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016
Core service use during the review period: Enter 1 in place of day for the 1st visit etc.
Outpatient ambulatory health services	Date of service: __ __ / __ __ / __ __ □ Not documented
Oral health care	Date of service: __ __ / __ __ / __ __ □ Not documented
Early intervention services	Date of service: __ __ / __ __ / __ __ □ Not documented
Home health care	Date of service: __ __ / __ __ / __ __ □ Not documented
Home and community-based health services	Date of service: __ __ / __ __ / __ __ □ Not documented
Hospice services	Date of service: __ __ / __ __ / __ __ □ Not documented
Mental health services	Date of service: __ __ / __ __ / __ __ □ Not documented
Medical nutrition therapy	Date of service: __ __ / __ __ / __ __ □ Not documented
Medical case management (including treatment adherence)	Date of service: __ __ / __ __ / __ __ □ Not documented
Substance abuse services – outpatient	Date of service: __ __ / __ __ / __ __ □ Not documented
Local AIDS Pharmaceutical Assistance (APA)	Date of service: __ __ / __ __ / __ __ □ Not documented
Health Insurance Program (HIP)	Date of service: __ __ / __ __ / __ __ □ Not documented

Unique Client ID: [Generated by system] Review period is July 1, 2013 through June 30, 2016
Support service use during the review period: Enter 1 in place of day for the 1st visit etc.
Case management services – non-medical	Date of service: __ __ / __ __ / __ __ □ Not documented
Child care services	Date of service: __ __ / __ __ / __ __ □ Not documented
Developmental assessment/early intervention services	Date of service: __ __ / __ __ / __ __ □ Not documented
Emergency financial assistance	Date of service: __ __ / __ __ / __ __ □ Not documented
Food bank/home-delivered meals	Date of service: __ __ / __ __ / __ __ □ Not documented
Health education/risk reduction	Date of service: __ __ / __ __ / __ __ □ Not documented
Housing services	Date of service: __ __ / __ __ / __ __ □ Not documented
Legal services	Date of service: __ __ / __ __ / __ __ □ Not documented
Linguistic services	Date of service: __ __ / __ __ / __ __ □ Not documented
Transportation services	Date of service: __ __ / __ __ / __ __ □ Not documented
Outreach services	Date of service: __ __ / __ __ / __ __ □ Not documented
Permanency planning	Date of service: __ __ / __ __ / __ __ □ Not documented
Psychosocial support services	Date of service: __ __ / __ __ / __ __ □ Not documented
Referral for health care/supportive services	Date of service: __ __ / __ __ / __ __ □ Not documented
Rehabilitation services	Date of service: __ __ / __ __ / __ __ □ Not documented
Respite services	Date of service: __ __ / __ __ / __ __ □ Not documented
Substance abuse services – residential	Date of service: __ __ / __ __ / __ __ □ Not documented
Treatment adherence counseling	Date of service: __ __ / __ __ / __ __ □ Not documented

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