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  • Data Collection Form 1

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    Aiza Mazaredo
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    This document contains a sepsis registry data collection form that collects demographic information like age, gender, education level, clinical information like co-morbidities and vital signs, diagnostic tests performed and results, interventions provided, and clinical outcomes of patients being treated for sepsis. The form includes fields for patient ID, checkboxes, radio buttons, and spaces to enter values to standardize the collection of various data points about suspected sepsis cases.

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    DATA-COLLECTION-FORM-1

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    This document contains a sepsis registry data collection form that collects demographic information like age, gender, education level, clinical information like co-morbidities and vital signs, diagnostic tests performed and results, interventions provided, and clinical outcomes of patients being treated for sepsis. The form includes fields for patient ID, checkboxes, radio buttons, and spaces to enter values to standardize the collection of various data points about suspected sepsis cases.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    5 views2 pages

    Data Collection Form 1

    Uploaded by

    Aiza Mazaredo
    This document contains a sepsis registry data collection form that collects demographic information like age, gender, education level, clinical information like co-morbidities and vital signs, diagnostic tests performed and results, interventions provided, and clinical outcomes of patients being treated for sepsis. The form includes fields for patient ID, checkboxes, radio buttons, and spaces to enter values to standardize the collection of various data points about suspected sepsis cases.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    SEPSIS REGISTRY

    DATA COLLECTION FORM

    Patient #: _____________ (FORM FIELD)


    Demographic profile: ___________ (FORM FIELD)
    Age: _____ (years) (FORM FIELD)
    Gender: (RADIO)
    - Male, Female
    Highest Educational Attainment: (RADIO):
    - GS/HS Graduate, College Undergraduate, College Graduate

    Clinical Profile:
    Co-morbid condition: (CHECKBOX)
    - HYPERTENSION, CEREBROVASCULAR DISEASE/STROKE, DIABETES
    MELLITUS I, DIABTES MELLITUS II, Kidney Disease, Liver Disease, IMMUNE
    DISORDER, CANCER

    -(RADIO): 1 co-morbid, 2 co-morbid, >2 co-morbid

    qSOFA
    (RADIO) RR: >22/= breaths/min
    Yes, No, No record
    (RADIO) Altered mental status/GCS: </=14
    Yes, No, No record
    (RADIO) SBP: </= 100mmHG
    Yes, No, No record
    (CHECKBOX) Possible Site of Infection:
    - Lung, GUT, Skin/Soft, Cardiovascular,
    (FORM FIELD) Others (Specify)

    Diagnostic Intervention:
    Lactate:
    (RADIO) Yes, None taken
    (FORM FIELD) ____VALUE
    (RADIO) Normal, Elevated, No record
    Pro-calcitonin:
    (RADIO) Yes, None taken
    (FORM FIELD) ____VALUE
    (RADIO) Normal, Elevated, No record
    Culture:
    (RADIO) Yes, None taken
    (RADIO) Blood,Urine, Wound,
    (FORM FIELD) Others (Specify)
    Chest Xray:
    (RADIO) Yes, None taken
    Diagnosis: (FORM FIELD)
    ABG
    (RADIO) Yes, None taken
    (FORM FIELD) pH _____, HCO3 _____, PCO2 _____, BE _____,
    O2 Saturation _____

    Intervention:

    Initial Fluid Resuscitation:


    (RADIO)
    30cc/kg: Yes, No record
    <30cc/kg: Yes, No record
    No fluid hydration: Yes, No record

    Norepinephrine added:
    (RADIO) Yes, No
    (FORM FIELD) If Yes, Specify dose:

    Antibiotic given:
    (RADIO) Yes, No
    (CHECKLIST) If Yes, <1 hour from arrival, 2-4 hours, > 4 hours

    Airway/Breathing management: 
    (RADIO) Yes, No, No record
    (FORM FIELD) Please specify management: ___________

    Clinical Outcome:
    (CHECKLIST) ED Disposition: Home, Non-critical bed, Monitored/Critical 
    (FORM FIELD) Length of Hospital Stay: ______ days
    (RADIO) Mortality in 30 days:  Yes, No

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