Acute Care (Inpatient) Case Abstract - Brands Delmar ...€¦ · Acute Care (Inpatient) Case...

Acute Care (Inpatient) Case Abstract

ALFRED STATE MEDICAL CENTER ACUTE CARE (INPATIENT) CASE ABSTRACT

01 Hospital Number

02 Patient Date of Birth

Month Day Year (YYYY)

03 Patient Gender

1 Male 2 Female 3 Other 4 Unknown

04A Race

1 American Indian/Eskimo/Aleut 2 Asian or Pacific Islander 3 Black 4 White 5 Other 6 Unknown

04B Ethnicity

1 Spanish origin/Hispanic 2 Non-Spanish origin/Non-Hispanic 3 Unknown

05A Living Arrangement

1 Alone 2 With spouse 3 With children 4 With parent or guardian 5 With relative other than spouse 6 With nonrelatives 7 Unknown

05B Marital Status

1 Married 2 Single 3 Divorced 4 Separated 5 Unknown

06 Hospital Number

07 Admission Date and Hour

Month Day Year (YYYY)

Military Time

08 Type of Admission

1 Scheduled 2 Unscheduled

09 Discharge Date and Time

Month Day Year (YYYY)

Military Time

10 Attending Physician Number

11 Operating Physician Number

12 Principal Diagnosis Code

. ICD Code

16 Birth Weight of Neonate

Kilograms

Date Abstract Completed

Month Day Year (YYYY)

17 Procedures, Dates, and Operating Physician UPIN

.

Month Day Year (YYYY)

UPIN

13 Other Diagnosis Code(s)

14 Qualifiers for Other Diagnoses

1 Onset preceded hospital admission 2 Onset followed hospital admission 3 Uncertain whether onset preceded or followed hospital admission

.

Month Day Year (YYYY)

UPIN

. ICD Code

.

Month Day Year (YYYY)

UPIN

. ICD Code

.

Month Day Year (YYYY)

UPIN

.

ICD Code

.

Month Day Year (YYYY)

UPIN

.

ICD Code

.

Month Day Year (YYYY)

UPIN

.

ICD Code

.

Month Day Year (YYYY)

UPIN

.

ICD Code

.

Month Day Year (YYYY)

UPIN

19 Patient’s Expected Payment Source

1 Blue Cross/Blue Shield 2 Other commercial insurance 3 Other liability insurance 4 Medicare 5 Medicaid 6 Workers’ Compensation 7 Self-insured employer plan 8 Health maintenance organization (HMO)

9 TRICARE 10 CHAMPVA 11 Other government payer 12 Self-pay 13 No charge (e.g., charity, special research, teaching) 14 Other

15 External Cause of Injury Codes

.

ICD E-code

.

ICD E-code

.

ICD E-code

.

ICD E-code

.

ICD E-code

18 Disposition 1 Discharged to home 2 Discharged to acute care hospital 3 Discharged to nursing facility 4 Discharged home to be under the care of a home health service (including hospice) 5 Discharged to other health care facility 6 Left against medical advice (AMA) 7 Alive, other 8 Died

20 Total Charges

$ , .