Medical Record Abstraction Form for Domestic Bombing Events

Data capture regarding the diagnosis and treatment of injuries is important to quantify the true impact of a disaster. This one-page form allows public health personnel, at the city, county, state, or federal level, to quickly extract basic medical information from hospital and emergency medical services’ records in order to advise officials as to the immediate impact of the event and the potential need for special resources (e.g., blood products, types of medical personnel, etc.). The form contains data elements regarding when and how injured persons arrived for hospital care, who administered their initial care, basic details regarding individuals’ location at the time of the blast if present in the chart documentation, basic categories of type of injury a person may have sustained, medical resources needed for initial treatment (such as x-rays or blood transfusions), types of physicians involved in initial care (such as trauma surgeons, orthopedic surgeons, etc.), and disposition, i.e., treated and released, admitted to the hospital, deceased. The form is designed to be used for chart extraction purposes only. No interviews are needed to obtain data.

Download the printable form [PDF - 43 KB]