Variable / Field Name,Form Name,Section Header,Field Type,Field Label,"Choices, Calculations, OR Slider Labels",Field Note,Text Validation Type OR Show Slider Number,Text Validation Min,Text Validation Max,Identifier?,Branching Logic (Show field only if...),Required Field?,Custom Alignment,Question Number (surveys only),Matrix Group Name,Matrix Ranking?,Field Annotation
recordid,record_id,,text,"",,,,,,,,y,,,,,
inclusion_chop,phi_chop,,yesno,"Does patient meet ALL of the following inclusion criteria?
1) Age < 10 years age at start of encounter
2) Clinical evaluation performed by child abuse specialist during the enrollment period due to recent concerns (within 1 month) for physical abuse. Clinical evaluation is defined to have occurred when a child abuse specialist documents an assessment of abuse or and/or recommendations for the evaluation or reporting of abuse in the medical record.
3) Patient physically seen within CAPNET system.
CHILD DOES NOT MEET INCLUSION CRITERIA. DO NOT PROCEED WITH DATA ENTRY FOR THIS CHILD.
Date of birth
Do NOT enter CAPNET case until DOB is known.
MRN
If entering temporary MRN, please make sure to come back and record accurate MRN when available.
Make sure MRN is unique to this case. If MRN has already been entered in database, add new consult as a second episode for the same child.
If form is complete, select ""Complete"", click ""Save & Stay"", then [event_1_arm_1][form-link:static_demographics:CLICK HERE] to go to the Static Demographics Form.
Does patient meet ALL of the following inclusion criteria?
1) Age < 10 years age at start of encounter
2) Clinical evaluation performed by child abuse specialist during the enrollment period due to recent concerns (within 1 month) for physical abuse. Clinical evaluation is defined to have occurred when a child abuse specialist documents an assessment of abuse or and/or recommendations for the evaluation or reporting of abuse in the medical record.
3) Patient physically seen within CAPNET system.
CHILD DOES NOT MEET INCLUSION CRITERIA. DO NOT PROCEED WITH DATA ENTRY FOR THIS CHILD.
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
DATA ENTRY STATUS & DUE DATES
| CASE MONTH | DATA ENRTY STATUS |
| November 2021 | Active - Due 1/17/2022 |
| October 2021 | Active - Due 12/13/2021 |
| Feb - September 2021 | COMPLETED |
*If you have a case from a month for which data entry has closed, please email capnetdcc@chop.edu.
Does patient meet ALL of the following inclusion criteria?
1) Age < 10 years age at start of encounter
2) Clinical evaluation performed by child abuse specialist during the enrollment period due to recent concerns (within 1 month) for physical abuse. Clinical evaluation is defined to have occurred when a child abuse specialist documents an assessment of abuse or and/or recommendations for the evaluation or reporting of abuse in the medical record.
3) Patient physically seen within CAPNET system.
CHILD DOES NOT MEET INCLUSION CRITERIA. DO NOT PROCEED WITH DATA ENTRY FOR THIS CHILD.
MRN:
If entering temporary MRN, please make sure to come back and record accurate MRN when available.
PENN STATE: DO NOT ENTER AN MRN. MRN field will disapear when form is saved.
Date of birth:
Do NOT enter CAPNET case until DOB is known.
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
If form is complete, select ""Complete"", click ""Save & Stay"", then [episode_arm_1][form-link:visit_date_providers_chop: CLICK HERE] to go to the Visit Date & Providers Form.
If form is complete, select ""Complete"", click ""Save & Stay"", then [episode_arm_1][form-link:visit_date_providers: CLICK HERE] to go to the Visit Date & Providers Form.
A CAPNET episode is the period inclusive of all signs, symptoms, and medical encounters associated with the specific injury or illness for which the CAP consultation was initiated. The initial hospitalization, all follow-up medical testing (including FUSS, OI testing, or other imaging or radiology) and the initial period of active consultation with child protective services and law enforcement. A new episode should be created if the child returns with new concerns for abuse.
",,,,,,,,,,,,,
dataentry_2,visit_date_providers_chop,,descriptive,"DATA ENTRY STATUS & DUE DATES
| CASE MONTH | DATA ENTRY STATUS |
| November 2021 | Active - Due 1/17/2022 |
| October 2021 | Active - Due 12/13/2021 |
| February- September 2021 | COMPLETED |
*If you have a case from a month for which data entry has closed, please email capnetdcc@chop.edu.
Date of the first consultation
First, consult occurs when CAP first documents recommendations for evaluation or management of suspected child abuse.
Date of Encounter/Date of Admission:
For all patients admitted to the hospital during this CAPNET episode, please use the date of hospital admission. For all other encounters, please use the date of first contact (phone or visit) with CAP provider during this CAPNET episode.
Date of Discharge from Hospital:
If child is not yet discharged at 42 days after admission date, enter -9996.""
If form is complete, select ""Complete"", click ""Save & Stay"", then [episode_arm_1][form-link:demographics: CLICK HERE] to go to the Demographics Form.
",,,,,,,,,,,,,
this_episode_descrip2,visit_date_providers,,descriptive,"A CAPNET episode is the period inclusive of all signs, symptoms, and medical encounters associated with the specific injury or illness for which the CAP consultation was initiated. The initial hospitalization, all follow-up medical testing (including FUSS, OI testing, or other imaging or radiology) and the initial period of active consultation with child protective services and law enforcement. A new episode should be created if the child returns with new concerns for abuse.
",,,,,,,,,,,,,
dataentry_3,visit_date_providers,,descriptive,"DATA ENTRY STATUS & DUE DATES
| CASE MONTH | DATA ENTRY STATUS |
| November 2021 | Active - Due 1/17/2022 |
| October 2021 | Active - Due 12/13/2021 |
| February- September 2021 | COMPLETED |
*If you have a case from a month for which data entry has closed, please email capnetdcc@chop.edu.
Date of Encounter/Date of Admission:
For all patients admitted to the hospital during this CAPNET episode, please use the date of hospital admission. For all other encounters, please use the date of first contact (phone or visit) with CAP provider during this CAPNET episode.
Date of the first consultation
First, consult occurs when CAP first documents recommendations for evaluation or management of suspected child abuse.
Date of Discharge from Hospital:
If child is not yet discharged at 42 days after admission date, enter -9996."".
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
DATA ENTRY STATUS & DUE DATES
| CASE MONTH | DATA ENRTY STATUS |
| November 2021 | Active - 1/17/2022 |
| October 2021 | Active - 12/13/2021 |
| FEB - September 2021 | COMPLETED |
*If you have a case from a month for which data entry has closed, please email capnetdcc@chop.edu.
Calculated Age @ time of admission
| Age in Days | Age in Months | Age in Years |
| {age_days:icons} | {age_months} | {age_years} |
Calculated Age @ time of first consultation
| Age in Days | Age in Months | Age in Years |
| {age_consult_days:icons} | {age_consult_months} | {age_consult_years} |
Calculated Age @ time of admission (Colorado)
| Age in Days | Age in Months | Age in Years |
| {age_days_col:icons} | {age_months_col} | {age_years_col} |
Calculated Age @ time of first consultation (Colorado)
| Age in Days | Age in Months | Age in Years |
| {age_consult_days_col:icons} | {age_consult_months_col} | {age_consult_years_col} |
Date of Visit
| Month of Visit | Year of Visit |
| {month_of_visit} | {year_of_visit} |
Date of Consult
| Month of Consult | Year of Consult |
| {month_of_consult} | {year_of_consult} |
Date of Visit - Colorado
| Month of Visit | Year of Visit |
| {month_of_visit_col} | {year_of_visit_col} |
Date of Consult - Colorado
| Month of Consult | Year of Consult |
| {month_of_consult_col} | {year_of_consult_col} |
YOU HAVE INDICATED THAT THE SUBJECT IS <= 0 DAYS OLD. PLEASE CHECK DATE OF VISIT AND DATE OR BIRTH FIELDS FOR ACCURACY.
Based on the Date of Birth & Date of Encounter this patient is >= 10 years old and DOES NOT meet inclusion criteria. If dates are incorrect, please correct.
Residence Location
*Start typing in the county name and it will automatically provide options. If 'other', type in 'other.
| County & State | Zip Code |
| {county_pennstate:icons} {county_colorado:icons} {county_kansas:icons} {county_utah:icons} {county_ohio:icons} {county_carolina:icons} {county_pitt:icons} {county_texas:icons} {county_chop:icons} {county_minnesota:icons} {county_sandiego:icons} | {zip_code:icons} |
Other County: {county_other:icons}
Other State: {state_other}
Health Insurance (what is listed in EMR, regardless of who pays for visit)
Source & Setting of Patient Evaluation
Source: Select who initiated contact with the child abuse team. If sibling evaluation, please select source of consult for index child.
Setting: Select setting for initial evaluation of patient by CAP. If initial contact was via phone but then child was seen in person, select the initial in-person location.
| Source of Consult / Referral | Initial Setting for Evaluation |
| {source:icons} {other_source:icons} Select all that apply | {setting:icons} {other_setting:icons} |
Source of consult / referral
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
Hover over words for definitions.
Past Medical History
",checkbox,"Known Past Medical History
Select all that apply
Does this child have a history of any of the following prior to this CAPNET episode:
Select all that apply. Relevant injuries and symptoms captured in a prior CAPNET episode should be included as well.
Please document if these signs of possible TBI were present regardless if child had history of head trauma.
Please include all reported priory injuries even if attributed to an accidental mechanism.
| Injuries | Signs of possible prior TBI |
| {prior_injury:icons} Includes injuries documented in medical record OR reported by a caregiver. | {prior_tbihistory:icons} Field only appears for children < 4 years old. |
Is there a history of any of the following injury(ies) prior to this CAPNET episode:
Does this child have a history of any of the following symptoms concerning for missed or occult head injury prior to this illness?
Select all that apply
Describe the other prior known and documented symptoms concerning for missed or occult head trauma:
Prior Neglect
",checkbox,"Is there a history of neglect known to the CAP?
Select all that apply
Prior Child Protective Services (CPS) Involvement Related to this Child
",radio,"Is there history of CPS involvement prior to this CAPNET episode?
Psychosocial concerns known to CAP related to caregiver(s)
",radio,CPS involvement as a caregiver prior to this episode,"1, Yes | 0, No | 97, Unknown/Not assessed",,,,,,,y,,,caregiver_psychsoc,,"3/16/21 Changed from collecting data on ""Primary caregivers"" defined as ""Primary caregiver refers to the person(s) who have the greatest responsibility for the daily care and rearing of a child. This is typically a parent, but may also refer to grandparent(s), legal guardian(s), or other adult(s) in a child's life"" to ""Caregivers"" defined as ""Caregiver(s) refers to the person(s) who (during the episode of illness) have responsibility for the care and rearing of a child. This is typically a parent, but may also refer to grandparents, legal guardians, babysitters, or other adults in a child's life."""
cg_placement,medical_and_social_history,,radio,Placement of any child in out-of-home care as a result of prior CAN,"1, Yes | 0, No | 97, Unknown/Not assessed",,,,,,,y,,,caregiver_psychsoc,,"3/16/21 Changed from collecting data on ""Primary caregivers"" defined as ""Primary caregiver refers to the person(s) who have the greatest responsibility for the daily care and rearing of a child. This is typically a parent, but may also refer to grandparent(s), legal guardian(s), or other adult(s) in a child's life"" to ""Caregivers"" defined as ""Caregiver(s) refers to the person(s) who (during the episode of illness) have responsibility for the care and rearing of a child. This is typically a parent, but may also refer to grandparents, legal guardians, babysitters, or other adults in a child's life."""
cg_mental,medical_and_social_history,,radio,Mental health concerns,"1, Yes | 0, No | 97, Unknown/Not assessed",,,,,,,y,,,caregiver_psychsoc,,"3/16/21 Changed from collecting data on ""Primary caregivers"" defined as ""Primary caregiver refers to the person(s) who have the greatest responsibility for the daily care and rearing of a child. This is typically a parent, but may also refer to grandparent(s), legal guardian(s), or other adult(s) in a child's life"" to ""Caregivers"" defined as ""Caregiver(s) refers to the person(s) who (during the episode of illness) have responsibility for the care and rearing of a child. This is typically a parent, but may also refer to grandparents, legal guardians, babysitters, or other adults in a child's life."""
cg_substance,medical_and_social_history,,radio,Problem substance use,"1, Yes | 0, No | 97, Unknown/Not assessed",,,,,,,y,,,caregiver_psychsoc,,"3/16/21 Changed from collecting data on ""Primary caregivers"" defined as ""Primary caregiver refers to the person(s) who have the greatest responsibility for the daily care and rearing of a child. This is typically a parent, but may also refer to grandparent(s), legal guardian(s), or other adult(s) in a child's life"" to ""Caregivers"" defined as ""Caregiver(s) refers to the person(s) who (during the episode of illness) have responsibility for the care and rearing of a child. This is typically a parent, but may also refer to grandparents, legal guardians, babysitters, or other adults in a child's life."""
cg_ipv,medical_and_social_history,,radio,Intimate Partner Violence (IPV),"1, Yes | 0, No | 97, Unknown/Not assessed",,,,,,,y,,,caregiver_psychsoc,,"3/16/21 Changed from collecting data on ""Primary caregivers"" defined as ""Primary caregiver refers to the person(s) who have the greatest responsibility for the daily care and rearing of a child. This is typically a parent, but may also refer to grandparent(s), legal guardian(s), or other adult(s) in a child's life"" to ""Caregivers"" defined as ""Caregiver(s) refers to the person(s) who (during the episode of illness) have responsibility for the care and rearing of a child. This is typically a parent, but may also refer to grandparents, legal guardians, babysitters, or other adults in a child's life."""
cg_criminal,medical_and_social_history,,radio,Criminal history,"1, Yes | 0, No | 97, Unknown/Not assessed",,,,,,,y,,,caregiver_psychsoc,,"3/16/21 Changed from collecting data on ""Primary caregivers"" defined as ""Primary caregiver refers to the person(s) who have the greatest responsibility for the daily care and rearing of a child. This is typically a parent, but may also refer to grandparent(s), legal guardian(s), or other adult(s) in a child's life"" to ""Caregivers"" defined as ""Caregiver(s) refers to the person(s) who (during the episode of illness) have responsibility for the care and rearing of a child. This is typically a parent, but may also refer to grandparents, legal guardians, babysitters, or other adults in a child's life."""
psysoc_careg_desc,medical_and_social_history,,text,List any other psychosocial concerns in the caregivers:,,Optional - add details if needed,,,,,,,,,,,
instruction_4,medical_and_social_history,,descriptive,"If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
Hover over words for definitions.
Chief complaint provided / Reason child was initially brought for care.
Select all that apply
| Did the child present with a history of trauma? (even if trauma history is not plausible). | Did child present with any of the following chief complaints? | Did the child present for exposure to family violence? |
| {trauma:icons} Self-inflicted trauma should be categorized as accidental. | {chiefcomplaint:icons} | {famviolence:icons} If yes, describe: {famviolence_describe:icons} |
Did the child present with a history of trauma?
Select all that apply
Chief Complaints
Select all that apply
Did the child present due to exposure for family violence?
Select all that apply
Was a history of trauma given LATER in this evaluation?
Select all that apply
Characteristics of Inflicted Trauma
| Reported Mechanism(s) | Number of Perpetrators | Perpetrator Relationship(s) | Perpetrator Gender(s) |
| {inflictedmech:icons} Select all that apply | {numberperp:icons} | {inflictedperp:icons} Select all that apply | {inflictedgender:icons} Select all that apply |
Reported mechanism of inflicted trauma?
Select all that apply
Reported perpetrator of inflicted trauma?
Select all that apply
Reported mechanism of accidental injury
Select all that apply
Describe the trauma attributed to self harming behaviors.
Describe the trauma attributed to a collision.
Fall Details
| Fall Location | Was the child carried? | Fall Height |
| {fall_mech:icons} | {fall_carried} | {fall_feet:icons}{fall_step:icons} |
| Was the child in a device ? |
| {fall_device:icons} |
Was the child in a device ?
How did history change?
Select all that apply
Did child present with any of the following symptoms?
Select all that apply
| Neurologic | Cardio-respiartory | Cutaneous / Oral |
| {present_neuro:icons} | {present_cardio:icons} | {present_cutan:icons} |
| Gastrointestinal | Musculoskeletal |
| {present_gi:icons} | {present_msk:icons} |
Presenting neurological symptom(s)
Select all that apply
Cutaneous / oral symptom(s)
Select all that apply
Presenting musculoskeletal symptom(s)
Select all that apply
Presenting GI symptom(s)
Select all that apply
Presenting cardio-respiratory symptom(s)
Select all that apply
Please select injury(ies)/findings that prompted the evaluation for abuse.
Please select all that apply.
The purpose of this question is to identify the injuries that led to an abuse work-up versus those that were found on that work-up.
For example, if child presents with a swollen leg and is found to have a CML that prompts a head CT showing a SDH. Choose fracture because CML led to evaluation for abuse. (See FAQ for additional details and scenarios.)
Was the delay unreasonable?
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
Hover over words for definitions.
Physical Examination Findings
",descriptive,"Were any of the following findings identified on any physical examination during this episode of care?
Select all that apply
| Cutaneous/Scalp [Include injuries. No need to include birthmarks or other non-trauma findings] [Code swelling and bruising separately for scalp lesions] | Neurologic |
| {cutaneous:icons} | {neurologic_signs:icons} |
| Oral [Includes bruising, petechiae, lacerations, tooth injuries and other injuries to the oral cavity.] | Ocular [Info on retinal hemorrhages will be collected separately] |
| {oral:icons} | {ocular:icons} |
| Other |
| {other_signs_symp:icons} |
Types of Cutaneous Injuries
Select all that apply
Bruises
| Number | Location | Patterned |
| {bruises_number:icons} *Enter the total number of bruises identified on exam. In some cases, the reported number of bruises will be imprecise because bruising may overlap, because multiple areas of bruising may or may not be counted as a single patterned bruise, or because CAPs may not have examined the child in person. In general, a patterned bruise with multiple components (e.g. a hand print) should be counted as a single bruise. | {bruises_location:icons} Select all that apply | {bruises_patterned:icons} If yes, describe: {descrip_pattern} |
Number of Bruises
In some cases, the reported number of bruises will be imprecise because bruising may overlap, because multiple areas of bruising may or may not be counted as a single patterned bruise, or because CAPs may not have examined the child in person. In general, a patterned bruise with multiple components (e.g. a hand print) should be counted as a single bruise.
Location of Bruising
Select all that apply
Burns
| Type | Location |
| {burn_type:icons} *Select all burn types identified. Scald burns result from contact with a hot liquid (other than grease) and include splash burns and immersion burns. | {burn_location:icons} Select all body locations where there is a burn identified |
| Total Surface Area | Burn Distribution | Maximum Burn Depth |
| {burn_surface_area:icons} *Include total surface area of all burns or all thicknesses. | {burn_distribution:icons} | {burn_depth:icons} |
Type of Burns
Select all that apply
Location of Burns
Select all that apply
Retinal Hemorrhages/Findings
Type of Ocular Injuries
Select all that apply
Retinal Hemorrhages : RIGHT EYE
| Number | Layer | Special Features |
| {rh_number_r:icons} | {rh_layer_r:icons} Select all that apply | {rh_features_r:icons} Select all that apply |
Retinal Hemorrhages : LEFT EYE
| Number | Layer | Special Features |
| {rh_number_l:icons} | {rh_layer_l:icons} Select all that apply | {rh_features_l:icons} Select all that apply |
Layers of Retinal Hemorrhages
Select all that apply
Layers of Retinal Hemorrhages
Select all that apply
Location of Oral Injuries
Select all that apply
Types of Neurological Signs
Select all that apply
Other Signs / Symptoms
Select all that apply
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
If the first lab of this CAPNET EPISODE was done prior to their transfer to CHOP, please use that. You will have to manually enter those lab values done at an OSH.
Collect labs sent within the first week following the CAP consult
Collect labs from follow-up visit if recommended by CAP
Note: labs not done within the first 7 days will not be pulled in automatically and should be entered manually if recommended by CAP
Enter first laboratory value for this CAPNET episode (even if from outside facility).
If value is <""XX"", enter ""XX"". For example, if lipase is < 30, enter 30.
",,"An injury is identified if the attending CAP would testify to the presence of the injury in the medical record, or in court.",,,,,[lab] = '1',,,,,, @NONEOFTHEABOVE=1
abdominal_lab,laboratory_testing,,checkbox,"Abdominal injury labs obtained
Select all that apply
Please select all of the laboratory studies performed:
Select all that apply
| Abdominal | Coagulation-Basic | Coagulation-Advanced | Bone Health (plasma/blood) | Toxicology |
| {abdominal_lab:icons} | {coagulation_lab:icons} | {coagulation_lab_2:icons} | {bonehealth_lab:icons} | {toxicology_lab:icons} |
For tests repeated multiple times, enter the first value in the CAPNET episode except for spurious values or lab errors.
Abdominal Laboratory Results
Abdominal Laboratory Results
| ALT (U/L) | AST (U/L) | Lipase (U/L) |
| {alt:icons} | {ast:icons} | {lipase:icons} |
For tests repeated multiple times, enter the first value in the CAPNET episode except for spurious values or lab errors.
Coagulation Laboratory Results
Basic Coagulation
Select all that apply
Advance Coagulation
Select all that apply
Coagulation Testing Results
| Hemoglobin (Hgb)(g/dl) | Platelet Count (Plt) (10font-size: 75%; vertical-align: super;"">9 L) | INR | PTT(sec) | Fibrinogen (mg/dl) |
| {hgb:icons} | {plt:icons} | {inr:icons} | {ptt:icons} | {fibrinogen:icons} |
For tests repeating multiple times, enter the first value in the CAPNET episode except for spurious values or lab errors.
Coagulation-Advanced Results
| von Willebrand Factor Activity (% or IU/dl) | von Willebrand Factor Antigen (% or IU/dl) | Factor VIII Assay (% or IU/dl) | Factor IX Assay (% or IU/dl) | Factor XIII Assay (% or IU/dl) | Factor XIII Assay |
| {vwf_activity:icons} | {vwf_antigen:icons} | {factorviii:icons} | {factorix:icons} | {factorxiii_quant:icons} | {factorxiii:icons} |
For tests repeating multiple times, enter the first value in the CAPNET episode except for spurious values or lab errors.
If a result is reported as IU/ml, convert to IU/dl by multiplying by 100.
Type(s) of Toxicology Testing Obtained:
Select all that apply
Do not include hospital administered medications
Toxicology Testing
Select all that apply. Exclude medications administered by medical providers.
| Source of Test | Category of Drug Identified | Specific Drug Identified |
| {tox_source:icons} | {tox_category:icons} | Please list: {drug_specific:icons} |
Toxicology Source
Select all that apply
Toxicology Results - Drug Class
Select all that apply
Bone Health Labs Obtained
Select all that apply
Bone Health Laboratory Evaluation
| Calcium (mg/dl) | Magnesium (mg/dl) | Phosphorus (mg/dl) | Alkaline Phosphatase (U/L) | Vitamin D 25-OH (ng/dl) | Parathyroid Hormone-intact/ iPTH (pg/ml) |
| {calcium:icons} | {magnesium:icons} | {phosphorus:icons} | {alkphos:icons} | {vitamind:icons} | {pth:icons} |
For tests repeating multiple times, enter the first value in the CAPNET episode except for spurious values or lab errors.
Other Laboratory Tests & Results
",yesno,Head circumference obtained?,,,,,,,"(
([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='Colorado' or [record-dag-label]='South Carolina' or [record-dag-label]='Pittsburgh' or [record-dag-label]='Minnesota') and
(
([episode_arm_1][age_years]<>"""" and [episode_arm_1][age_years]<3) or ([episode_arm_1][age_consult_years]<>"""" and [episode_arm_1][age_consult_years]<3)
)
or
( [record-dag-label]='Kansas City' and
(
([episode_arm_1][age_years]<>"""" and [episode_arm_1][age_years]<1) or ([episode_arm_1][age_consult_years]<>"""" and [episode_arm_1][age_consult_years]<1)
and
(
([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021) or ([episode_arm_1][month_of_visit]>3 or [episode_arm_1][month_of_consult]>3)
)
)
or
( [record-dag-label]='Nationwide' and
(
([episode_arm_1][age_years]<>"""" and [episode_arm_1][age_years]<1) or ([episode_arm_1][age_consult_years]<>"""" and [episode_arm_1][age_consult_years]<1)
)
and (([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021 ) or ([episode_arm_1][month_of_visit]>2 or [episode_arm_1][month_of_consult]>2)))
or
( [record-dag-label]='Texas' and
([episode_arm_1][age_years]<>"""" and [episode_arm_1][age_years]<2) or ([episode_arm_1][age_consult_years]<>"""" and [episode_arm_1][age_consult_years]<2)
and (([episode_arm_1][year_of_visit]>2021 or [episode_arm_1][year_of_consult]>2021) or ([episode_arm_1][month_of_visit]>4 or [episode_arm_1][month_of_consult]>4)))
)
)",y,,,,,"3/7/2021 Field added for sites collecting head circumference (CHOP, PITT, Colorado, Utah, MUSC) for children < 3years old.
5/12/2021 Field added for Kansas City and Nationwide for infants < 1 y.o.
8/23/2021 Field updated for Texas for infants form < 1 to < 2 y.o
10/4/2021: Field updated for Minnesota to < 3 years old
12/1/21: Update branching logic from (([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='Colorado' or [record-dag-label]='South Carolina' or [record-dag-label]='Pittsburgh' or [record-dag-label]='Minnesota') and [episode_arm_1][age_years]< 3) or
(( [record-dag-label]='Kansas City') and [episode_arm_1][age_years]< 1
and ( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>3))
or
( [record-dag-label]='Nationwide' and [episode_arm_1][age_years]< 1
and ( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>2))
or
( [record-dag-label]='Texas' and [episode_arm_1][age_years]< 2
and ( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>3)) to
(([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='Colorado' or [record-dag-label]='South Carolina' or [record-dag-label]='Pittsburgh' or [record-dag-label]='Minnesota') and ( [episode_arm_1][age_years]< 3 or [episode_arm_1][age_consult_years]< 3))
or
( [record-dag-label]='Kansas City' and ([episode_arm_1][age_years]< 1 or [episode_arm_1][age_consult_years]< 1)
and (([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021) or ([episode_arm_1][month_of_visit]>3 or [episode_arm_1][month_of_consult]>3)))
or
( [record-dag-label]='Nationwide' and ([episode_arm_1][age_years]< 1 or [episode_arm_1][age_consult_years]< 1 )
and (([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021 ) or ([episode_arm_1][month_of_visit]>2 or [episode_arm_1][month_of_consult]>2)))
or
( [record-dag-label]='Texas' and ([episode_arm_1][age_years]< 2 or [episode_arm_1][age_consult_years]< 2 )
and (([episode_arm_1][year_of_visit]>2021 or [episode_arm_1][year_of_consult]>2021) or ([episode_arm_1][month_of_visit]>3 or [episode_arm_1][month_of_consult]>3)))
12/6/21: update month of visit/month of consult- 4 for Texas"
hc_cm,laboratory_testing,,text,First head circumference measurement (in cm) during clinical encounter:,,,number,,,,"((([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='Colorado' or [record-dag-label]='South Carolina' or [record-dag-label]='Pittsburgh' or [record-dag-label]='Minnesota') and ( [episode_arm_1][age_years]<3 or [episode_arm_1][age_consult_years]<3))
or
( [record-dag-label]='Kansas City' and ([episode_arm_1][age_years]<1 or [episode_arm_1][age_consult_years]<1)
and (([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021) or ([episode_arm_1][month_of_visit]>3 or [episode_arm_1][month_of_consult]>3)))
or
( [record-dag-label]='Nationwide' and ([episode_arm_1][age_years]<1 or [episode_arm_1][age_consult_years]<1 )
and (([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021 ) or ([episode_arm_1][month_of_visit]>2 or [episode_arm_1][month_of_consult]>2)))
or
( [record-dag-label]='Texas' and ([episode_arm_1][age_years]<2 or [episode_arm_1][age_consult_years]<2 )
and (([episode_arm_1][year_of_visit]>2021 or [episode_arm_1][year_of_consult]>2021) or ([episode_arm_1][month_of_visit]>4 or [episode_arm_1][month_of_consult]>4)))) and [episode_arm_1][hc_obtain]!=0",y,,,,,"5/12/2021 Field added for Texas, Kansas City and Nationwide.
8/23/2021 Field updated for Texas from < 1 to < 2
12/1/21: Update branching logic from ((([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='Colorado' or [record-dag-label]='South Carolina' or [record-dag-label]='Pittsburgh' or [record-dag-label]='Minnesota') and [episode_arm_1][age_years]<3) or
(( [record-dag-label]='Kansas City') and [episode_arm_1][age_years]<1
and ( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>3))
or
( [record-dag-label]='Nationwide' and [episode_arm_1][age_years]<1
and ( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>2))
or
( [record-dag-label]='Texas' and [episode_arm_1][age_years]<2
and ( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>4))) and [episode_arm_1][hc_obtain]!=0 to
((([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='Colorado' or [record-dag-label]='South Carolina' or [record-dag-label]='Pittsburgh' or [record-dag-label]='Minnesota') and ( [episode_arm_1][age_years]<3 or [episode_arm_1][age_consult_years]<3))
or
( [record-dag-label]='Kansas City' and ([episode_arm_1][age_years]<1 or [episode_arm_1][age_consult_years]<1)
and (([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021) or ([episode_arm_1][month_of_visit]>3 or [episode_arm_1][month_of_consult]>3)))
or
( [record-dag-label]='Nationwide' and ([episode_arm_1][age_years]<1 or [episode_arm_1][age_consult_years]<1 )
and (([episode_arm_1][year_of_visit]>=2021 or [episode_arm_1][year_of_consult]>=2021 ) or ([episode_arm_1][month_of_visit]>2 or [episode_arm_1][month_of_consult]>2)))
or
( [record-dag-label]='Texas' and ([episode_arm_1][age_years]<2 or [episode_arm_1][age_consult_years]<2 )
and (([episode_arm_1][year_of_visit]>2021 or [episode_arm_1][year_of_consult]>2021) or ([episode_arm_1][month_of_visit]>4 or [episode_arm_1][month_of_consult]>4)))) and [episode_arm_1][hc_obtain]!=0"
hc_ptile,laboratory_testing,,text,"First head circumference measurement's percentile during clinical encounter:
Other Important Lab Tests and Results
Please list any additional lab tests and results that were important in the child abuse evaluation?
Hover over words for definitions.
Radiologic Testing
",checkbox,"Radiologic studies obtained
Select all that apply
Skeletal Imaging
A fracture is identified if the attending CAP would testify to the presence of the fracture in the medical record, or in court.
If x-rays of a previously identified fracture are purposefully omitted from the SS and the SS does not identify any additional fracture, select “Identifies Only Previously Known Fractures.
FUSS: Please include results from FUSS's performed between 1 to 8 weeks after initial SS.
REMINDER: Update # of fractures after filling in FUSS results if needed.
| Skeletal Imaging | Results of Initial Skeletal Survey | Results of FUSS | Results of Bone Scan |
| {skeletal_image:icons} Select all that apply. | {ss_result:icons} If indeterminate finding on SS is confirmed as a definite fracture on additional plain films, code as ""New fracture"" If indeterminate finding on SS is confirmed as a definite fracture on additional FUSS or other imaging modality, code as ""Raises concern for possible fracture"" | {fuss_result:icons} Select all that apply | {bonescan_result:icons} |
Skeletal imaging performed:
Select all that apply
Spine imaging performed
Select all that apply
FUSS Results
Select all that apply
Neuroimaging
Select final determination based on all neuroimaging performed. (e.g. If CT suggests an injury but MRI does not and final assessment by CAP is that there is no injury, code as ""No Injuries"". If CT and MRI both identify a SDH, code as ""New Injury"". If CT and MRI show ONLY a skull fracture already seen by skeletal survey, code as ""Known injury only"").
Do not include scalp swelling identified on neuroimaging as a new injury.
| Type of Neuroimaging Performed | Results of Neuroimaging |
| {neuroimage_type:icons} Select all that apply | {neuroimage_result:icons} |
Abdominal imaging
| Type of Abdominal Imaging Performed | Results of Abdominal Imaging |
| {abdimage_type:icons} Select all that apply | {abdimage_result:icons} |
Chest Imaging
| Type of Chest Imaging Performed | Results of Chest Imaging |
| {chestimage_type:icons} Select all that apply | {chestimage_result:icons} |
Spine Imaging
| Type of Spine Imaging Performed | Results of Spine Imaging |
| {spine_image:icons} Select all that apply | {spineimage_result:icons} |
Abdominal/thoracic imaging performed:
Select all that apply
Chest imaging performed:
Select all that apply
Neuroimaging performed
Select all that apply
Describe the other neuroimaging that was performed:
EEG
",yesno,Was an EEG obtained?,,,,,,,"(( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>8) )
or (( [episode_arm_1][year_of_consult]>2021 or [episode_arm_1][month_of_consult]>11) )",y,,,,,"Field added 8/5/2021 for any cases entered with visit dates of September 2021 or later.
12/1/21: Updated branching logic from ( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>8) to (( [episode_arm_1][year_of_visit]>2021 or [episode_arm_1][month_of_visit]>8) )
or (( [episode_arm_1][year_of_consult]>2021 or [episode_arm_1][month_of_consult]>11) )"
eeg_result,radiologic_testing,,checkbox,"EEG Results
Please include summative results of all EEGs obtained during this episode of care. Select all that apply
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
Injury Types Identified
[An injury is identified if the attending CAP would testify to the presence of the injury in the medical record, or in court]
Select all that apply
Locations of Fractures Identified
Select all fracture locations that are present.
CML fractures include classic metaphyseal fractures, corner fractures, metaphyseal chip fractures and bucket Handle fractures.
| Axial Fractures | Appendicular Fractures (non-CML) | Classic Metaphyseal Fracture(s) CML(s) |
| {axial_fracture:icons} | {append_fracture:icons} | {cml_fracture:icons} |
Fracture Instructions
| Location | Select all locations (bones) where a definite fracture is identified. |
| Morphology | For each frature location, select all fractures morphologies that are present. |
| Age | Select all fracture ages (acute or healing) at time of first imaging. Healing fractures have radiographic signs of healing such as periosteal reaction, callus formation, marginal sclerosis, remodeling, loss of fracture line. |
| Side | Indicate if fracture is on right or left side of body. If there are bilateral fratures, select right and left. |
CHOP data entry tip: If the fracture is described as ""spiral"", ""oblique"", ""buckle"", ""mid-shaft"" or ""transverse"", it will not be a CML fracture.
Axial Fractures
Select all that apply
Skull Fractures
Select all skull fracture locations and morphologies that apply.
| Number | Location(s) | Morphology(ies) | Side |
| {skull_number:icons} *# of distinct skull fractures. | {skull_location:icons} | {skull_morphology:icons} | {skull_side:icons} |
Skull Fracture Location(s)
Select all that apply
Skull Fracture Morphology(ies)
Select all that apply
Skull Fracture Side
Select all that apply
Clavicle Fractures
| Number | Age(s) |
| {clavicle_number:icons} | {clavicle_age:icons} Select all that apply |
Clavicle Fracture Age
Select all that apply
Scapula Fracture(s)
Select all that apply
| Number | Location(s) | Age(s) |
| {scapula_num:icons} | {scapula_location:icons} | {scapula_age:icons} |
Scapula Fracture(s) Location(s)
Select all that apply
Scapula Fracture(s) Age
Select all that apply
Rib Fractures
Select all that apply
| Number | Location(s) | Side | Age(s) |
| {rib_number:icons} | {rib_location:icons} | {rib_side:icons} | {rib_age:icons} |
Rib Fractures Location
Select all that apply
Rib Fracture Side
Select all that apply
Rib Fracture Age
Select all that apply
Spine Fractures
Select all that apply
Fractures of the sacrum and coccyx are included in pelvic fractures and should not be entered in spine fracture section.
| Number | Location(s) / Type | Level | Age(s) |
| {spine_number:icons} | {spine_type:icons} | {spine_level:icons} | {spine_age:icons} |
Spine Fracture Location/Type
Select all that apply
Spine Fracture Level
Select all that apply
Spine Fracture Age
Select all that apply
Pelvic Fractures
Select all that apply
| Number | Location(s) | Age(s) |
| {pelvic_num:icons} | {pelvic_location:icons} | {pelvic_age:icons} |
Pelvic Fracture(s) Location(s)
Select all that apply
Pelvic Fracture(s) Age
Select all that apply
Sternum Fractures
| Number | Age(s) |
| {sternum_num:icons} | {sternum_age:icons} Select all that apply |
Sternum Fracture(s) Age
Select all that apply
Other Axial Fracture(s)
Enter information here for a fracture in a bone NOT listed above.
| Number | Location(s) | Age(s) |
| {fracture_other_num:icons} | {fracture_other_locations:icons} | {fracture_other_age:icons} Select all that apply |
Other Axial Fracture Age(s)
Select all that apply
Appendicular Fractures (Non-CML)
Appendicular Fracture Locations
Select all that apply
Humerus Fracture(s)
Select all that apply
| Number | Morphology(ies) | Age(s) |
| {humerus_number:icons} | {humerus_type:icons} | {humerus_age:icons} |
Humerus Fracture Type
Select all that apply
Humerus Fracture Age
Select all that apply
Radius Fracture(s)
Select all that apply
| Number | Morphology(ies) | Age(s) |
| {radius_number:icons} | {radius_type:icons} | {radius_age:icons} |
Radius Fracture Type
Select all that apply
Radius Fracture Age
Select all that apply
Ulna Fracture(s)
Select all that apply
| Number | Morphology(ies) | Age(s) |
| {ulna_number:icons} | {ulna_type:icons} | {ulna_age:icons} |
Ulna Fracture Age
Select all that apply
Femur Fracture(s)
Select all that apply
| Number | Morphology(ies) | Age(s) |
| {femur_number:icons} | {femur_type:icons} | {femur_age:icons} |
Ulna Fracture Type
Select all that apply
Femur Fracture Type
Select all that apply
Femur Fracture Age
Select all that apply
Tibia Fracture(s)
Select all that apply
| Number | Morphology(ies) | Age(s) |
| {tibia_number:icons} | {tibia_type:icons} | {tibia_age:icons} |
Tibia Fracture Type
Select all that apply
Fibula Fracture(s)
Select all that apply
| Number | Morphology(ies) | Age(s) |
| {fibula_number:icons} | {fibula_type:icons} | {fibula_age:icons} |
Hand Fracture(s)
Select all that apply
Carpal bones include: scaphoid, lunate, triquetum, pisiform, trapezium, trapezoid, capitate, hamate.
| Number | Location(s) | Age(s) |
| {hand_number:icons} | {hand_loc:icons} | {hand_age:icons} |
Foot Fracture(s)
Select all that apply
| Number | Location(s) | Age(s) |
| {feet_number:icons} | {feet_loc:icons} | {feet_age:icons} |
Classic Metaphyseal Fractures (CMLs) Number
Please enter the number of CML fractures in each location with at least one CML fracture.
| Radius | Ulna | Humerus | Tibia | Fibula | Femur |
| {cml_radius_num:icons} | {cml_ulna_num:icons} | {cml_humerus_num:icons} | {cml_tibia_num:icons} | {cml_fibula_num:icons} | {cml_femur_num:icons} |
Intracranial Injuries / Findings
Intracranial Findings
Select all that apply
Skull fractures should be listed in fracture section and NOT in intracranial findings.
Do not include scalp swelling as an intracranial injury.
| Hemorrhage | Parenchymal Injury | Other |
| {ich_type:icons} | {parenchymal_injury:icons} | {extraaxial_findings:icons} |
Please select the pattern of SDH identified:
Select all that apply
Abdominal / Visceral / Chest Injuries & Findings
Abdominal/Visceral Injury Type
Select all that apply
| Select Hepatic Injury Grade | Hepatic Injury Grade Definitions |
| {hepatic_grade} | | Grade | Injury Type | Description of Injury | | I | Hematoma | Subcapsular, < 10% surface area | | Laceration | Capsular tear, < 1cm ; parenchymal depth | | II | Hematoma | Subcapsular, 10%-50% surface area ; intraparenchymal < 10 cm in diameter | | Laceration | Capsular tear, 1-3cm parenchymal depth, < 10 cm in length | | III | Hematoma | Subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding | | Laceration | >3 cm parenchymal depth | | IV | Laceration | Parenchymal disruption involing 25-75% hepatic lobe or 1-3 Couinaud's segments | | V | Laceration | Parenchymal disruption involing >75% of hepatic lobe or >3 Couinaud's segments within a single lobe | | Vascular | Juxtahepatic venous injuries; ie, retrohepatic vena cava/central major hepatic veins | | VI | Vascular | Hepatic avulsion | |
| Select Splenic Injury Grade | Splenic Grade Definitions |
| {spleen_grade} | | Grade | Injury Type | Description of Injury | | I | Hematoma | Subcapsular, < 10% surface area | | Laceration | Capsular tear, < 1cm ; parenchymal depth | | II | Hematoma | Subcapsular, 10%-50% surface area ; intraparenchymal, < 5 cm in diameter | | Laceration | Capsular tear, 1-3cm parenchymal depth that does not involve a trabecular vessel | | III | Hematoma | Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >=5 cm or expanding | | Laceration | >3 cm parenchymal depth or involving trabecular vessels | | IV | Laceration | Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) | | V | Laceration | Completely shattered spleen | | Vascular | Hilar vascular injury with devascularizes spleen | |
| Select Pancreatic Injury Grade | Pancreatic Grade Definitions |
| {pancreatic_grade} | | Grade | Injury Type | Description of Injury | | I | Hematoma | Minor contusion without duct injury | | Laceration | Superficial laceration without duct injury | | II | Hematoma | Major contusion without duct injury or tissue loss | | Laceration | Major laceration without duct injury or tissue loss | | III | Laceration | Distal transection or parenchymal injury with duct injury | | IV | Laceration | Proximal transection or parenchymal injury involving ampulla | | V | Laceration | Massive disruption of pancreatic head | |
| Select Renal Injury Grade | Renal Grade Definitions |
| {renal_grade} | | Grade | Injury Type | Description of Injury | | I | Contusion | Microscopic or gross hematuria, urologic studies normal | | Hematoma | Subcapsular, nonexpanding without parenchymal laceration | | II | Hematoma | Nonexpanding perirenal hematoma confirmed to renal retroperitoneum | | Laceration | < 1.0cm parenchymal depth of renal cortex without urinary extravasation | | III | Laceration | >1.0cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation | IV
| Laceration | Parenchymal laceration extending through renal cortex, medulla, and collecting system | | Vascular | Main renal artery or vein injury with contained hemorrhage | | V | Laceration | Completely shattered kidney | | Vascular | Avulsion of renal hilum which devascularizes kidney | |
| Select Adrenal Injury Grade | Adrenal Grade Definitions |
| {adrenal_grade} | | Grade | Description of Injury | | I | Contusion | | II | Laceration involving only cortex (< 2cm) | | III | Laceration extending into medulla (>=2cm) | | IV | >50% parenchymal destruction | | V | Total parenchymal destruction (including massive intraparenchymal hemorrhage) ; Avulsion from blood supply | |
Bowel Injury Details
Select all that apply
| Location | Type |
| {bowel_location:icons} | {bowel_type:icons} |
Spine Finding (Non-fracture)
Spine Injuries
Please include spine fractures under fracture section
Select all that apply
Other Conditions & Diagnoses
Select all that apply
| Were any medical conditions identifed that predisposed the child to injuries? {predisposemimic:icons} Were these known prior to this episode of care? {predispose_known:icons} | {bonefragility:icons} {coagmimic:icons} |
| Did the child have a finding that was mistaken for a traumatic injury by a medical provider? {findingmimic:icons} | {findingmimic_other} |
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
Hover over words for definitions.
Level of Concern for Physical Abuse
",radio,Level of Concern for Physical Abuse,"1, 1. Definitely Not Physical Abuse | 2, 2. No Concern for Physical Abuse | 3, 3. Mildly Concerning for Physical Abuse | 4, 4. Intermediately Concerning for Physical Abuse | 5, 5. Very Concerning for Inflicted Physical Abuse | 6, 6. Substantial Evidence of Physical Abuse | 7, 7. Definite Physical Abuse","Abusive trauma includes any non-accidental trauma to the child and may include striking, kicking, burning, shaking, biting, forced ingestion, or any action that results in a physical impairment of the child or creates risk of physical impairment",,,,,,y,,,,,
phabscoringguidelines,outcomes,,descriptive,Please see the attached physical abuse concern guidelines.,,,,,,,,,,,,,
care_level,outcomes,"Level of Medical Care Required
",radio,Highest Level of Care Required,"1, Outpatient or Emergency Department Only | 2, Inpatient Admission or Observation | 3, ICU / PICU / NICU / Step down",,,,,,,y,,,,,
icu_los,outcomes,,text,ICU Length of Stay (days),,"Please count each ""Midnight"" that a child spent in the ICU as one day. Example: If a child was admitted at 10pm Monday and discharged at 3pm the following Wednesday, this would be counted as 2 ICU days (2 midnights)",integer,0,,,[episode_arm_1][care_level] = '3',y,,,,,
admitted_nonchop_outcomes,outcomes,,calc,Does admitted_nonchop = 1?,"if([episode_arm_1][admitted_nonchop][current-instance]=1, 1, '')","1= yes, admitted_nonchop is 1",,,,,,,,,,, @HIDDEN
hospital_los,outcomes,,calc,Hospital Length of Stay (days),"if(
(([episode_arm_1][discharge_date_nonchop]="""" and [episode_arm_1][discharge_date_chop]="""") or (([episode_arm_1][visit_date_nonchop][current-instance]="""" and [episode_arm_1][admit_date_nonchop][current-instance]="""") and ([episode_arm_1][visit_date_chop][current-instance]="""" and [episode_arm_1][admit_date_chop][current-instance]=""""))),"""",
if(
([episode_arm_1][discharge_date_nonchop]=""-9996"" or [episode_arm_1][discharge_date_chop]=""-9996""),43,
if([episode_arm_1][visit_date_nonchop][current-instance]<>"""", rounddown(datediff([episode_arm_1][visit_date_nonchop][current-instance], [episode_arm_1][discharge_date_nonchop], ""d"", ""mdy""), 1),
if([episode_arm_1][visit_date_chop][current-instance]<>"""", rounddown(datediff([episode_arm_1][visit_date_chop][current-instance], [episode_arm_1][discharge_date_chop], ""d"", ""mdy""), 1),
if([episode_arm_1][admit_date_nonchop][current-instance]<>"""", rounddown(datediff([episode_arm_1][admit_date_nonchop][current-instance], [episode_arm_1][discharge_date_nonchop], ""d"", ""mdy""), 1),
if([episode_arm_1][admit_date_chop][current-instance]<>"""", rounddown(datediff([episode_arm_1][admit_date_chop][current-instance], [episode_arm_1][discharge_date_chop], ""d"", ""mdy""), 1), '')
)
)
)
)
)",,,,,,[episode_arm_1][admitted_nonchop] = '1' and [record-dag-label]!='Colorado' or [episode_arm_1][admitted_chop] = '1',y,,,,,"if(
([episode_arm_1][discharge_date_nonchop]="""" and [episode_arm_1][discharge_date_chop]="""") or ([episode_arm_1][visit_date_nonchop][current-instance]="""" and [episode_arm_1][visit_date_chop][current-instance]=""""),"""",
if(
([episode_arm_1][discharge_date_nonchop]=""-9996"" or [episode_arm_1][discharge_date_chop]=""-9996""),""43"",
if([episode_arm_1][visit_date_nonchop][current-instance]<>"""", rounddown(datediff([episode_arm_1][visit_date_nonchop][current-instance], [episode_arm_1][discharge_date_nonchop], ""d"", ""mdy""), 1),
rounddown(datediff([episode_arm_1][visit_date_chop][current-instance], [episode_arm_1][discharge_date_chop], ""d"", ""mdy""), 1))))
if([episode_arm_1][visit_date_nonchop][current-instance]<>"""", rounddown(datediff([episode_arm_1][visit_date_nonchop][current-instance], [episode_arm_1][discharge_date_nonchop], ""d"", ""MDY""), 1), rounddown(datediff([episode_arm_1][visit_date_chop][current-instance], [episode_arm_1][discharge_date_chop], ""d"", ""MDY""),1))"
hospital_los_col,outcomes,,text,Hospital Length of Stay (days),,,number,,,,[episode_arm_1][admitted_nonchop] = '1' and [record-dag-label]='Colorado',y,,,,,9/15/21: Created this field for Colorado dag to enter LOS
near_fatality,outcomes,,checkbox,"Did the patient have any of the following as a result of suspected abuse or neglect?
CPS Reporting
",yesno,"Reported to CPS prior to initiation of CAP consult?
Would you have reported if the case had not previously been reported (given the information available from the initial CAP evaluation)?
Given the information available from the initial CAP evaluation. If CPS data are available at the time of the initial CAP evaluation (as when you are consulted by CPS), you may use these data in your determination.
Select all that apply
Would you have reported if the case had not previously been reported (given the information available from the initial CAP evaluation)?
Given the information available from the initial CAP evaluation. If CPS data are available at the time of the initial CAP evaluation (as when you are consulted by CPS), you may use these data in your determination.
Select all that apply
Which other form of suspected maltreatment would you have reported for?
Select all that apply
Reported to CPS during/after consult.
Select all that apply
Which other form of suspected maltreatment was reported as a result of your evaluation?
Select all that apply
Initial CPS & Legal Outcomes
",checkbox,"Were any of the following events known to occur during initial management period related to maltreatment of the child?
Select all that apply
Initial CPS & Legal Outcome Matrix
",radio,"Safety Plan / Restrictions","1, Yes | 0, No | 97, Unknown",,,,,,(([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='South Carolina' or [record-dag-label]='Colorado') and ([episode_arm_1][capreport(98)] = '1' or [episode_arm_1][capreport(1)] = '1' or [episode_arm_1][capagreedcpsreport_new(98)] = '1' or [episode_arm_1][capagreedcpsreport_new(1)] = '1') and [episode_arm_1][management_yn]='1'),,,,management_matrix,,
managment_kinship,outcomes,,radio,"Kinship Placement","1, Yes | 0, No | 97, Unknown",,,,,,(([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='South Carolina' or [record-dag-label]='Colorado') and ([episode_arm_1][capreport(98)] = '1' or [episode_arm_1][capreport(1)] = '1' or [episode_arm_1][capagreedcpsreport_new(98)] = '1' or [episode_arm_1][capagreedcpsreport_new(1)] = '1') and [episode_arm_1][management_yn]='1'),,,,management_matrix,,
management_foster,outcomes,,radio,"Unrelated foster placement","1, Yes | 0, No | 97, Unknown",,,,,,(([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='South Carolina' or [record-dag-label]='Colorado') and ([episode_arm_1][capreport(98)] = '1' or [episode_arm_1][capreport(1)] = '1' or [episode_arm_1][capagreedcpsreport_new(98)] = '1' or [episode_arm_1][capagreedcpsreport_new(1)] = '1') and [episode_arm_1][management_yn]='1'),,,,management_matrix,,
management_custody,outcomes,,radio,"Change in Custody","1, Yes | 0, No | 97, Unknown",,,,,,(([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='South Carolina' or [record-dag-label]='Colorado') and ([episode_arm_1][capreport(98)] = '1' or [episode_arm_1][capreport(1)] = '1' or [episode_arm_1][capagreedcpsreport_new(98)] = '1' or [episode_arm_1][capagreedcpsreport_new(1)] = '1') and [episode_arm_1][management_yn]='1'),,,,management_matrix,,
management_confession,outcomes,,radio,Confession / Report of harm by the perpetrator,"1, Yes | 0, No | 97, Unknown",,,,,,(([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='South Carolina' or [record-dag-label]='Colorado') and ([episode_arm_1][capreport(98)] = '1' or [episode_arm_1][capreport(1)] = '1' or [episode_arm_1][capagreedcpsreport_new(98)] = '1' or [episode_arm_1][capagreedcpsreport_new(1)] = '1') and [episode_arm_1][management_yn]='1'),,,,management_matrix,,
management_arrest,outcomes,,radio,Arrest / Criminal charges,"1, Yes | 0, No | 97, Unknown",,,,,,(([record-dag-label]='CHOP' or [record-dag-label]='Utah' or [record-dag-label]='South Carolina' or [record-dag-label]='Colorado') and ([episode_arm_1][capreport(98)] = '1' or [episode_arm_1][capreport(1)] = '1' or [episode_arm_1][capagreedcpsreport_new(98)] = '1' or [episode_arm_1][capagreedcpsreport_new(1)] = '1') and [episode_arm_1][management_yn]='1'),,,,management_matrix,,
pending,outcomes,"Pending Results
",radio,What is the status of this consultation?,"1, Complete, no tests pending | 2, Tests pending | 3, There were pending tests but now the consult is complete",Please include pending tests relevant to the CAP evaluation.,,,,,,y,,,,,
pending_describe,outcomes,,notes,Please describe what is pending:,,,,,,,[episode_arm_1][pending] = '2',y,,,,,
list_pending,outcomes,,descriptive,"Below are imaging data fields with pending results. Once the result is no longer listed as pending, it will no longer appear below. Please resolve these before closing out the record.
PENDING - Initial Skeletal Survey Findings (Form: Physical Abuse - Testing Performed)
PENDING - FUSS Results (Form: Physical Abuse - Testing Performed)
PENDING - Spine Results (Form: Physical Abuse - Testing Performed)
PENDING - Neuroimaging Results (Form: Physical Abuse - Testing Performed)
PENDING - EEG Results (Form: Physical Abuse - Testing Performed)
PENDING - Abdominal CT/MRI Results (Form: Physical Abuse - Testing Performed)
PENDING - Chest CT/MRI Results (Form: Physical Abuse - Testing Performed)
You indicated there were tests previously pending that are now complete. Please make sure to: 1) Fill in the results of the tests and, 2) update CPS reporting (if appropriate), 3) update CPS & legal outcomes (if appropriate), 4) update level of certainty (if appropriate).
If form is complete, select
""Complete"" and then select ""
Save & Go to Next Form"".
If information is still pending, leave as ""Incomplete"" and then select ""Save & Go to Next Form"".
If you selected ""yes"" on Demographics form that this child is a contact of a previously entered CAPNET subject, you do not need to enter data on this Contacts Form because the data is captured with the initial CAPNET subject.
Definition: a CONTACT CHILD is a child < 10 years old who shares a care environment where there is suspected physical abuse.
Please list all contact children even if they presented with independent concerns for abuse or are being entered as a separate CAPNET case (even if suspicion is low after consult).
How many contacts (< 10 years old) were identified during this CAPNET episode?
Please enter data for the 6 youngest contacts below.
| Sex | Age | Relationship | Level of Evaluation |
| {contact1_sex:icons} | Age (years): {contact1_age_y:icons} Age (months):{contact1_age_m:icons} | {contact1_relationship:icons} | {contact1_level:icons} |
If contact child is less than 1 year old, enter ""0"" for age in years and then enter age in months.
If a contact is under 10 years old but the exact age in years is is not known, enter -9997 for age.
| Physical Exam | Skeletal Survey | Neuroimaging | Other Testing / Results |
| {physical1:icons} {physical1_positive} | {skeletal1:icons} {skeletal1_positive} | {neuro1:icons} {neuro1_positive} | {othertests_1:icons} Including SS for kids >3 and neuroimaging for kids >1 |
What age was the contact [in years]?
What age was the contact [in months]?
| Sex | Age | Relationship | Level of Evaluation |
| {contact2_sex:icons} | Age (years): {contact2_age_y:icons} Age (months):{contact2_age_m:icons} | {contact2_relationship:icons} | {contact2_level:icons} |
If contact child is less than 1 year old, enter ""0"" for age in years and then enter age in months.
If a contact is under 10 years old but the exact age in years is is not known, enter -9997 for age.
| Physical Exam | Skeletal Survey | Neuroimaging | Other Testing / Results |
| {physical2:icons} {physical2_positive} | {skeletal2:icons} {skeletal2_positive} | {neuro2:icons} {neuro2_positive} | {othertests_2:icons} Including SS for kids >3 and neuroimaging for kids >1 |
What age was the contact [in years]?
What age was the contact [in months]?
| Sex | Age | Relationship | Level of Evaluation |
| {contact3_sex:icons} | Age (years): {contact3_age_y:icons} Age (months):{contact3_age_m:icons} | {contact3_relationship:icons} | {contact3_level:icons} |
If contact child is less than 1 year old, enter ""0"" for age in years and then enter age in months.
If a contact is under 10 years old but the exact age in years is is not known, enter -9997 for age.
| Physical Exam | Skeletal Survey | Neuroimaging | Other Testing / Results |
| {physical3:icons} {physical3_positive} | {skeletal3:icons} {skeletal3_positive} | {neuro3:icons} {neuro3_positive} | {othertests_3:icons} Including SS for kids >3 and neuroimaging for kids >1 |
What age was the contact [in years]?
What age was the contact [in months]?
| Sex | Age | Relationship | Level of Evaluation |
| {contact4_sex:icons} | Age (years): {contact4_age_y:icons} Age (months):{contact4_age_m:icons} | {contact4_relationship:icons} | {contact4_level:icons} |
If contact child is less than 1 year old, enter ""0"" for age in years and then enter age in months.
If a contact is under 10 years old but the exact age in years is is not known, enter -9997 for age.
| Physical Exam | Skeletal Survey | Neuroimaging | Other Testing / Results |
| {physical4:icons} {physical4_positive} | {skeletal4:icons} {skeletal4_positive} | {neuro4:icons} {neuro4_positive} | {othertests_4:icons} Including SS for kids >3 and neuroimaging for kids >1 |
What age was the contact [in years]?
What age was the contact [in months]?
| Sex | Age | Relationship | Level of Evaluation |
| {contact5_sex:icons} | Age (years): {contact5_age_y:icons} Age (months):{contact5_age_m:icons} | {contact5_relationship:icons} | {contact5_level:icons} |
If contact child is less than 1 year old, enter ""0"" for age in years and then enter age in months.
If a contact is under 10 years old but the exact age in years is is not known, enter -9997 for age.
| Physical Exam | Skeletal Survey | Neuroimaging | Other Testing / Results |
| {physical5:icons} {physical5_positive} | {skeletal5:icons} {skeletal5_positive} | {neuro5:icons} {neuro5_positive} | {othertests_5:icons} Including SS for kids >3 and neuroimaging for kids >1 |
What age was the contact [in years]?
What age was the contact [in months]?
| Sex | Age | Relationship | Level of Evaluation |
| {contact6_sex:icons} | Age (years): {contact6_age_y:icons} Age (months):{contact6_age_m:icons} | {contact6_relationship:icons} | {contact6_level:icons} |
If contact child is less than 1 year old, enter ""0"" for age in years and then enter age in months.
If a contact is under 10 years old but the exact age in years is is not known, enter -9997 for age.
| Physical Exam | Skeletal Survey | Neuroimaging | Other Testing / Results |
| {physical6:icons} {physical6_positive} | {skeletal6:icons} {skeletal6_positive} | {neuro6:icons} {neuro6_positive} | {othertests_6:icons} Including SS for kids >3 and neuroimaging for kids >1 |
What age was the contact [in years]?
What age was the contact [in months]?
Complex Contact Situations
If the CAP team was aware of additional children sharing a care environment where there was suspected physical abuse but had limited information related to numbers, ages, or shared risk and limited ability to make formal recommendations for evaluation (e.g., daycare, school, religious institution, unusual household arrangement, other), please provide available information.
ADD NEW RECORD FOR CONTACTS WITH FULL CAPNET EVALUATION
After all contacts are entered, Select ""
Complete"" and click ""
Save & Stay"".
Click here to add a new record for EACH contact that meets Meets CAPNET Inclusion Criteria. OR go to ""Add / Edit Record"" on the left hand menu to manually add new record(s).
Make sure to link the new record to this current record (record id: [recordid]) on the Demographics Form.