Agency for Toxic Substances and Disease Registry



Veterinary Chart Abstraction FormReviewer Name: ________________________Date of Review: ___ / ___ / ____ Data entered: ___ / ___ / ____Veterinary Hospital: _______________________________ Pet ID: _________Pet Name: _____________________________ Owner’s Name: ______________________________________ Address: Street: ___________________________ City: ___________________ State: _____ Zip: _____________ Telephone (Home) ______________(Cell) ______________(Work) ______________(Other) ______________ Patient DemographicsAge: ____ □ Years □ MonthsSex: □ Male □ Female □ Neutered/SpayedSpecies: □ Dog □ Cat □ Other _______________________Breed: _______________________________ Hair Length: □ Short □ Medium □ Long □ Hairless □ N/ABody Condition Score: ____ Visit InformationDate of Visit: ____ / ____ / ______ Time of arrival: ____:____ □ am □ pm MM DD YYYYChief Complaint: ___________________________________________________________________________________Was the patient admitted? □ Y □ N If yes, # Days: ______Initial Vital Signs: Weight: ________ □ kg □ lb Temp (°F): ________ Heart Rate: _______ Respiratory Rate: _______ O2 sat: ________ Medical History __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medications: Heartworm prevention □ Y □ N______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Decontamination Was the patient decontaminated? □ Yes □ No □ N/A If yes, where was the patient decontaminated? How was the patient decontaminated?□ In the field/At site□ Water□ At veterinary hospital□ Soap and water□ Both□ Other: ___________________________ □ Other: ________________________________Clinical SignsCheck box if the sign is present in the medical record (for this encounter). If date of onset is different from date of presentation, indicate in date column.Sign DateGeneral□ Fever (>103.0 °F)*___ / ___ / ____□ Hypothermia (<98.0 °F)* ___ / ___ / ____□ Lethargy___ / ___ / ____□ Other: _____________________ / ___ / ____□ Other: _____________________ / ___ / ____Eye□ Corneal abrasion___ / ___ / ____□ Increased tearing___ / ___ / ____□ Irritation/Pain___ / ___ / ____□ Itching/Pruritis___ / ___ / ____□ Miosis___ / ___ / ____□ Mydriasis___ / ___ / ____□ Other: _____________________ / ___ / ____Cardiovascular□ Bradycardia*___ / ___ / ____□ Cardiac arrest___ / ___ / ____□ Hypertension___ / ___ / ____□ Hypotension___ / ___ / ____□ Tachycardia*___ / ___ / ____□ Other: _____________________ / ___ / ____Respiratory□ Cough___ / ___ / ____□ Cyanosis___ / ___ / ____□ Dyspnea___ / ___ / ____□ Hyperventilation/Tachypnea___ / ___ / ____□ Nose bleed___ / ___ / ____□ Phlegm/Congestion___ / ___ / ____□ Runny nose___ / ___ / ____□ Stridor___ / ___ / ____□ Wheezing___ / ___ / ____ □ Other: _____________________ / ___ / ____Gastrointestinal□ Abdominal pain___ / ___ / ____□ Anorexia___ / ___ / ____□ Constipation___ / ___ / ____□ Diarrhea___ / ___ / ____□ Nausea___ / ___ / ____□ Vomiting___ / ___ / ____□ Other: _____________________ / ___ / ____Sign DateNervous System□ Ataxia___ / ___ / ____□ Fasciculations___ / ___ / ____□ Hyperactive/anxiety/irritable___ / ___ / ____□ Muscle pain___ / ___ / ____□ Muscle rigidity___ / ___ / ____□ Muscle weakness___ / ___ / ____□ Paralysis___ / ___ / ____□ Peripheral neuropathy___ / ___ / ____□ Salivation___ / ___ / ____□ Other: _____________________ / ___ / ____Skin□ Burns___ / ___ / ____□ Edema/Swelling___ / ___ / ____□ Erythema/Redness/Flushing___ / ___ / ____□ Hives/Welts___ / ___ / ____□ Irritation/Pain___ / ___ / ____□ Itching/Pruritis___ / ___ / ____□ Rash___ / ___ / ____□ Other: _____________________ / ___ / ____*Normal value varies by speciesImagingDateType of ImagingLocationContrastAcute FindingsDescription of Acute Findings___ / ___ / ____□ X-ray□ Ultrasound □ Other: ____________________□ Y□ N□ Y□ N___ / ___ / ____□ X-ray□ Ultrasound □ Other: ____________________□ Y□ N□ Y□ N___ / ___ / ____□ X-ray□ Ultrasound □ Other: ____________________□ Y□ N□ Y□ N___ / ___ / ____□ X-ray□ Ultrasound □ Other: ____________________□ Y□ N□ Y□ NEKGDateFindingsDescription of EKG Findings___ / ___ / ____□ WNL□ Abnl, consistent□ Abnl, new___ / ___ / ____□ WNL□ Abnl, consistent□ Abnl, newWNL- within normal limitsAbnl, consistent- Abnormal finding, consistent with medical history or previous diseaseAbnl, new- Abnormal finding, may indicate the presence of new diseaseLab Values (See key below for check box explanations)(Only record actual value if it is initially abnormal or becomes abnormal. Do not record normal values.)LabRepeat Lab Values (if necessary)Na_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________K_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Cl_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________HCO3-_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________BUN_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Cr_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Glu_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Hgb_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Hct_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________WBC_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Plts_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Ca2+_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________AST_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________ALT_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Total Bili_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Alk Phos_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Other:_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Other:_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Other:_______□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________UrinalysisDate: ___ / ___ / ____Repeat Lab Values (if necessary)pH□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Specific Gravity□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Protein□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Glucose□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Ketones□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________WBC□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________RBC□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, other Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Bilirubin□ WNL□ Abnl, CI □ Abnl, C Dz□ Abnl, exposure□ Abnl, otherDate: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________Date: ___ / ___ / ___ Time: ____:____ □ am □ pm _______________WNL- Within normal limitsAbnl, CI- Abnormal, Clinically insignificant (To be determined with NCEH Toxicologists)Abnl, C Dz- Abnormal finding, consistent with documented chronic diseaseAbnl, exposure- Abnormal finding, potentially associated with the exposureAbnl, other- Clinically significant abnormality, related to other disease processArterial Blood Gas (ABG) Flow SheetDate Date Date Date TimeTimeTimeTimepHpHpHpHpO2pO2pO2pO2pCO2pCO2pCO2pCO2HCO3-HCO3-HCO3-HCO3-O2 satO2 satO2 satO2 satSupplemental O2 □ Y □ N □ N/ASupplemental O2 □ Y □ N □ N/AcSupplemental O2 □ Y □ N □ N/ASupplemental O2 □ Y □ N □ N/AMedications (new medications that were initiated or prescribed during this visit/admission)NameIndicationGiven during this visit?Continued after discharge?OutcomesDiagnosis: _________________________________________________________________________________________Discharge □ LWBS□ Office visit□ Admitted: ___ / ___ /____ Discharge information: Date: ___ / ___ /____ Time: ____: _____ □ am □ pm□ Died: ___ / ___ /____ Cause of death: _________________________________________________________________Necropsy performed? □ Yes □ No □ If yes, where? _______________________________________________________________________________Necropsy findings: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________□ Other: ___________________________________LWBS- Left without being seen ................
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