SPOKANE REGIONAL HEALTH DISTRICT
PHONE 509-323-2851
FAX 509-324-1408
WWW.SRHD.ORG
DOH 348-082 Jan 2016
MEDICAL COMPLICATIONS REPORTING FORM
COLORECTAL CANCER SCREENING AND DIAGNOSIS
Initial Reporting Date: Click here to enter a date.
Follow-Up Date: Click here to enter a date.
Follow-Up Date: Click here to enter a date.
Follow-Up Date: Click here to enter a date.
Number Criteria
1
2
3
4
5
6
7
CCDE Med-IT ID Number: Click here to enter text.
Region: Choose an item.
Response
Procedure related to medical complication
Choose an item.
Indication for Examination
Choose an item.
Results of Examination:
Choose an item.
Bowel Preparation Adequate
Choose an item.
Segment reached (if sigmoidoscopy or colonoscopy
Choose an item.
Difficult Examination
Choose an item.
Biopsy/polypectomy performed
Choose an item.
Procedure(s)/Technique(s) performed
Check all that apply:
done)
Submucosal injection
Snare polypectomy
Hot biopsy forceps or cautery
8
Cold biopsy
Ablation
Medical Complication(s)
Control of bleeding
Unknown
Other
Click here to enter text.
Check all that apply:
Emergency Room visit
Bleeding
Cardiopulmonary events
Complications related to
anesthesia
9
Perforation
Other
Click here to enter text.
Death
Cause of Death:
Click here to enter text.
Excessive abdominal pain
For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY 711).
DOH 348-082 Jan 2016
SPOKANE REGIONAL HEALTH DISTRICT
PHONE 509-323-2851
FAX 509-324-1408
WWW.SRHD.ORG
Number Criteria
Client Medications
10
Response
Check all that apply:
Aspirin
Number
Inhaled corticosteroids
H2 Blockers
Oral corticosteroids
NSAIDS
Proton pump inhibitor
Anticoagulants
None
Other
Hospital Admission Required
11
Current Status of Client
Click here to enter text.
Choose an item.
Hospital Admission Date: Click here to enter a date.
Hospital Discharge Date: Click here to enter a date.
Initial Status Narrative: Click here to enter text.
Follow-Up Narrative: Click here to enter text.
12
Follow-Up Narrative: Click here to enter text.
Interventions Performed to address
complications with pertinent dates
13
Follow-Up Narrative: Click here to enter text.
Initial Narrative: Click here to enter text.
Follow-Up Narrative: Click here to enter text.
Follow-Up Narrative: Click here to enter text.
Follow-Up Narrative: Click here to enter text.
Instructions:
Complete the form for medical complications resulting from screening or diagnostic purposes occurring during or within 30 days.
Medical Complications Requiring Hospitalization:
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Prime Contractors (PCs) should notify the Washington State Breast, Cervical and Colon Health Program (BCCHP) Public Health Nurse
Consultant (PHNC) within 24 hours of the notification of the hospitalization
The PHNC will notify the Centers for Disease Control and Prevention (CDC) technical assistance team by email within 36 hours of
notification
The PC will submit the form to the BCCHP PHNC within 2 days of notification of the hospitalization
The PHNC will submit the form to the CDC within 3 days of notification of the hospitalization
The form will be updated by the PC and the PHNC monthly or more frequently as the client’s status changes to CDC until resolved.
Updates require response to only require Questions #12 and #13 of the form.
Complete fields of the CCDE record in Med-IT on this client and submit when due
Medical Complications NOT Requiring Hospitalization:
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PCs should notify the Washington State BCCHP PHNC within 15 days of the notification of the complication
The BCCHP PHNC will notify the CDC quarterly on September 1 st, December 1st, March 1st and June 1st
The PC will submit the form to the BCCHP PHNC within 30 days of notification
The form will be updated by the PC and PHNC quarterly and submitted to CDC if the medical complication was not resolved within the
quarter period until resolution – Updates require response to Follow-up date, #12 and #13 of the form. Complete fields of the CCDE
record in Med-IT on this client and submit when due
For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY 711).