Module 6: Case
Report Form
(Chart Abstraction)
This training session contains
information regarding:


Overview the CRF
Highlights of certain points of data collection
from the medical record
At this point you have done the following:
Identified Eligible Respondents
Obtained Consent
Enrolled Respondents
Administered the ACP Questionnaire
Next… you will need to collect data from the
medical record into the Case Report Form
Completion (i.e. Chart Abstraction)
Identifying Respondents

In order for the site to be able to access the relevant
medical record, they will need to know the unique,
hospital assigned, medical record number. We
recommend keeping an identification list. You can find
a template on the study website.
What is a CRF?

Official clinical data collection document
Data abstracted from medical charts
 Allows for efficient and complete data
processing, analysis and reporting
 Study questions determine what data should be
collected on the CRF

CRF Worksheets

A tool to facilitate chart abstraction
Instructions
Worksheet
Tips for Completing Chart
Abstraction


Understand what kinds of data you are looking
for
Orient yourself to the various sections of your
local medical charts
Paper
 Electronic



Determine any local standards used to document
ACP/AD
Be clear on how information is recorded (e.g.
abbreviations, dose units, etc…)
Tips for Completing Chart
Abstraction con’t


Sometimes there are several sources for the
same information.
The best thing to do is be consistent.
Example:



Hospital Admission Date/Time
Arrival note listed on ambulance record
The first entry in the ED notes
Date/time logged in the hospital computer system
Types of CRF Data
Comprehensive instructions are available in the
CRF Worksheets. The following slides are meant
to highlight the types of data collection required.
Comorbidities


Patient characteristics that affect outcomes
Medical Chart sources of info:
Admission notes, ED assessments, previous
admission notes
 Progress notes
 Discharge Summary


Collect only those that appear on the CRF,
record them by:
Body system
 Illness/condition

CRF pg. 4-5
Vasopressors/Inotropes



From the current hospitalization
Usually only administered in the ICU or stepdown units.
Record any instance where an infusion is given
for > 30 mins


Don’t count boluses
Record start and stop dates
CRF pg. 6-7
Consultations

List all consultations that were ordered during
this hospital stay
RACE (Rapid Assessment of Critical Event) Team
or Code 66 or Code Blue
 Critical Care or Critical Care Outreach
 Home Care/Transition Services
 Social Work
 Spiritual Care
 Palliative Team
 Palliative Home Care
 Geriatrics Team
CRF pg. 8-9

Dialysis

Current hospitalization, new onset of acute
renal failure requiring any form of dialysis

Start and stop date for dialysis
CRF pg. 10-11
Percutaneous Feeding Tube

Percutaneous feeding tubes are those inserted through
the skin and into the stomach or intestine.



If nasoenteric or nasogastric do not record here
Indicate whether the patient arrived at the institution
with a percutaneous feeding tube already in place
(removal date)
Indicate if the patient ever had a percutaneous feeding
tube inserted during the current hospitalization
(insertion & removal dates)
CRF pg. 10-11
Mechanical Ventilation



Record if the patient received any ventilation (non-invasive
and/or invasive support) throughout the entire hospital
admission
Non-Invasive ventilation refers to all modalities of ventilation
that assist with breathing without the use of an endotracheal
tube. (BI-PAP, nasal or mask ventilation, mask CPAP)
Invasive mechanical ventilation refers to any mode of
intermittent positive pressure delivered via an oral/nasal tracheal
tube or tracheostomy with or without positive end expiratory
pressure and high frequency jet ventilation or oscillation.
Nasal prongs, facemask or supplementation O2 are NOT
considered ventilation since the patient still breathes
spontaneously.
CRF pg. 12-13
Mechanical Ventilation con’t

Record start and stop date/time for each episode


If stopped for > 48 hrs, then restarted, considered it a new
episode
Use ‘actual’ start date (ED, OR, etc), if initiated
externally (i.e. referring hospital) then enter the start
date/time as hospital admission
Mechanical Ventilation con’t

MV stop is when patient is off > 48 continuous
hrs
intubated or breathing through a t-tube OR
 tracheostomy mask breathing OR
 CPAP ≤ 5cmH2O without pressure support or
intermittent mandatory ventilation assistance


If transferred out of hospital while vented, stop
date is hospital discharge date/time
CPR Use in Hospital

CPR is defined as at least any one of the
following occurs:
Chest compressions
 Defibrillation
 Intubation (if not already intubated).


Enter each episode separately

If CPR was used multiple times in a day, please
document it only once.
CRF pg. 14-15
Goals of Care Discussions

Document any goals of care discussions from
the current hospitalization
CRF pg. 16-19
Goals of Care Discussions

Each instance in chronological order

Did the patient have an existing GoC in the medical
chart upon admission to hospital?


Yes → Record the GoC designation
Record all instances of GoC discussions from the
current hospitalization

Date of GoC discussion

Where did it occur (e.g. ER)
Date of GoC order written
 GoC decision made

Goals of Care Decision Made

Use the most appropriate GoC designation
system presented:
No decision made
 Decision made

No change from previous
 Change from previous:





Alberta
BC DNAR
BC MOST
All other regions
GoC – All other regions options

Goals of care designation – All other regions

The coordinator should use their own judgment
when determining how locally documented
designations translate into the options available on
the CRF
1 – Aggressive use of heroic measures….
 2 – Full medical care but in the event…
 3 – Doctors will be focused on my comfort…
 4 – A mix of the above…
 5 – Unsure, documentation unclear
 6 – no documentation
 7 - Other

Processes of Care
Upon Hospital Admission


Upon hospital admission + 1 day
Orders written to WITHHOLD LSTs




Ventilation
Vasopressors
Dialysis
CPR
WITHHOLDING LSTs = the patient is NOT
currently receiving the applicable life sustaining
therapy(ies) and then an order is written to never start
the therapy or re-start it.
CRF pg. 20-21
Upon Hospital Admission con’t

Enter the date the order was written.


If there are instances where multiple changes of
process of care orders are documented regarding
withholding care please collect the first order date
written to withhold therapy.
Withholding dialysis may not be written in the
doctor’s orders, it might be captured in the
progress notes. If this is the case then please use
the date the note was written.
Upon Hospital Admission con’t


Upon hospital admission + 1 day
Orders written to WITHDRAW LSTs
Ventilation
 Vasopressors
 Dialysis



WITHDRAWING LSTs is defined as currently
receiving any life sustaining therapy(ies) and
then an order is written to stop it for patients
whose outcome is not favourable.
Enter the date the order was written
Upon Hospital Admission con’t

End of life scenario, this does not apply for
orders written for stopping normal every day
treatment when no longer needed.
NO escalation of care orders



Receiving LSTs  no escalation = Withholding
Receiving LSTs  comfort measures = Withdrawing
Not receiving LSTs  no escalation = Withholding
Process of Care
During Hospitalization



After Admission orders – Discharge/Death
Orders written to WITHHOLD LSTs
Orders written to WITHDRAW LSTs
CRF pg. 22-23
Index Hospital Overview

Index hospitalization = Enter the date and time the
patient was admitted to hospital



initial presentation to ED or hospital ward (earliest)
Document all ICU and Step Down admission and
discharge dates/times chronologically for the entire
hospital stay
If patient dies in hospital, date/time of death =
discharge
CRF pg. 24-25
Hospital Discharge


For patients who are discharged to a Rehabilitation
ward within the institution, the date/time patient is
discharged from the hospital to the Rehabilitation ward
= hospital discharge
Indicate where the patient was discharged:






Home
Retirement Residence
Long Term Care or Nursing Home
Rehabilitation Facility
Ward in another hospital
If still in hospital at Day 90, check the
appropriate box.
Entering Data into REDCap

Once you have:
Administered the ACP questionnaire(s)
 Collected the CRF data
 Degree of system implementation

Proceed to enter the data into REDCap.

See Module 7 for instructions.
Training Module 6
Complete
Live Demo of REDCap
Navigation
Institutional Data
Patient and Family Members
ACP Questionnaires
Case Report Form
ReCap of REDCap
Institutional Data
Enter once per audit cycle
Patient/Family Member Data
Patients are enrolled on the
eScreening/Ernollment Log
Enrollment numbers
are automatically
inserted into REDCap
Enrollment #
ACP Questionnaire
Patient version
ACP Questionnaire
FM version
ACP Questionnaire
Case Report Form
The
Grid
Data Conventions in REDCap

Dates YYYY - MM - DD


A date picker calendar is available to enter dates.
Times HH:MM
24-hour period format i.e. 22:37. The semicolon
must be entered. Use leading zeros where applicable
i.e. 01:28.
 Midnight should be entered as 00:00


If data is NOT available use the “NA” options.
Lock your Data

Once you have entered all of your data select the
“Lock” button.

This tells us you have finished your data entry.
Error Messages
All errors must be addressed before you can LOCK
Technical Support

HELPDESK
http://www.ceru.ca/helpdesk/open.php

Important to provide a description of the error
message you are receiving:
Copy and paste to the Helpdesk
 Screen Shots (print screen, paste into a document,
send)

ACP Questionnaire: Section 4
Patients
who arrive
Patients
who
inarrive
hospital
in
with
AD in
hospital
place.
with AD in
place, but
there is a
change in
hospital
ACP Questionnaire: Section 6

Documentation of ACP/AD in Hospital Chart
at end of interview
Modification to response options for questions 1ci,
1cii, 2bi and 2bii
 If “yes,” in addition to recording the date, also
indicate the option chosen.

Example, 1ci

Goals of Care designation or MOST form
Yes/No
Date of Document
Option






Aggressive use of heroic measures and artificial life
sustaining treatments including CPR to keep me
alive at all.
Full medical care but in the event my heart stops, or
my breathing stops, No CPR
Doctors will be focused on my comfort and
alleviate suffering and not on being kept alive by
artificial means or heroic measures
A mix of the above options (e.g. try to fix problems
but if not getting better switch to focusing only on
my comfort even if it hastens death)
Unsure
Other ____________
Training Module 6
Complete